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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
A "TIER"

is a specific list of drugs. Your plan may have several tiers,and your copayment amount depends on which tier your drug is listed.Plans can choose their own tiers, so members should refer to their benefit booklet or contact the plan for more information.

ABSTRACT

Is the collection of information from the medical record via hard copy or electronic instrument.

ABUSE

A range of the following improper behaviors or billing practices including, but not limited to:

  • Billing for a non-covered service;
  • Misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered); or
  • Inappropriately allocating costs on a cost report
ABUSE (PERSONAL)

When another person does something on purpose that causes you mental or physical harm or pain.

ACCESS

Your ability to get needed medical care and services.

ACCESSIBILITY OF SERVICES

Your ability to get medical care and services when you need them.

ACCESSORY DWELLING UNIT (ADU)

A separate housing arrangement within a single-family home. The ADU is a complete living unit and includes a private kitchen and bath.

ACCREDITATION

An evaluative process in which a healthcare organization undergoes an examination of its policies, procedures and performance by an external organization ("accrediting body") to ensure that it is meeting predetermined criteria. It usually involves both on- and off-site surveys.

ACCREDITATION CYCLE FOR M+C DEEMING

The duration of CMS's recognition of the validity of an accrediting organization's determination that a Medicare + Choice organization (M+CO) is "fully accredited".

ACCREDITATION FOR DEEMING

Some States use the findings of private accreditation organizations, in part or in whole, to supplement or substitute for State oversight of some quality related standards. This is referred to as "deemed compliance" with a standard.

ACCREDITATION FOR PARTICIPATION

State requirement that plans must be accredited to participate in the Medicaid managed care program.

ACCREDITED (ACCREDITATION)

Means having a seal of approval. Being accredited means that a facility or health care organization has met certain quality standards. These standards are set by private, nationally recognized groups that check on the quality of care at health care facilities and organizations. Organizations that accredit Medicare Managed Care Plans include the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and the American Accreditation HealthCare Commission/URAC.

ACCREDITED STANDARDS COMMITTEE

An organization that has been accredited by ANSI for the development of American National Standards.

ACT/LAW/STATUTE

Term for legislation that passed through Congress and was signed by the President or passed over his veto.

ACTIVITIES OF DAILY LIVING (ADL)*

Activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating, and using the bathroom.

ACTUAL CHARGE

The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount Medicare approves. (See Approved Amount; Assignment.)

ACTUARIAL BALANCE

The difference between the summarized income rate and the summarized cost rate over a given valuation period.

ACTUARIAL DEFICIT

A negative actuarial balance.

ACTUARIAL RATES

One half of the expected monthly cost of the SMI program for each aged enrollee (for the aged actuarial rate) and one half of the expected monthly cost for each disabled enrollee (for the disabled actuarial rate) for the duration the rate is in effect.

ACTUARIAL SOUNDNESS

A measure of the adequacy of Hospital Insurance and Supplementary Medical Insurance financing as determined by the difference between trust fund assets and liabilities for specified periods.

ACTUARIAL STATUS

A measure of the adequacy of the financing as determined by the difference between assets and liabilities at the end of the periods for which financing was established.

ADDITIONAL BENEFITS

Health care services not covered by Medicare and reductions in premiums or cost sharing for Medicare-covered services. Additional benefits are specified by the MA Organization and are offered to Medicare beneficiaries at no additional premium. Those benefits must be at least equal in value to the adjusted excess amount calculated in the ACR. An excess amount is created when the average payment rate exceeds the adjusted community rate (as reduced by the actuarial value of coinsurance, copayments, and deductibles under Parts A and B of Medicare). The excess amount is then adjusted for any contributions to a stabilization fund. The remainder is the adjusted excess, which will be used to pay for services not covered by Medicare and/or will be used to reduce charges otherwise allowed for Medicare-covered services. Additional benefits can be subject to cost sharing by plan enrollees. Additional benefits can also be different for each MA plan offered to Medicare beneficiaries.

ADJUSTED AVERAGE PER CAPITA COST (AAPCC)

An estimate of how much Medicare will spend in a year for an average beneficiary. (See Risk Adjustment.)

ADJUSTED COMMUNITY RATING (ACR)

How premium rates are decided based on members' use of benefits and not their individual use of benefits.

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 COSTS

A general term that refers to Medicare and Medicaid administrative costs, as well as CMS administrative costs. Medicare administrative costs are comprised of the Medicare related outlays and non-CMS administrative outlays. Medicaid administrative costs refer to the Federal share of the States' expenditures for administration of the Medicaid program. CMS administrative costs are the costs of operating CMS (e.g., salaries and expenses, facilities, equipment, rent and utilities, etc.). These costs are reflected in the Program Management account.

ADMINISTRATIVE DATA

This refers to information that is collected, processed, and stored in automated information systems. Administrative data include enrollment or eligibility information, claims information, and managed care encounters. The claims and encounters may be for hospital and other facility services, professional services, prescription drug services, laboratory services, and so on.

ADMINISTRATIVE EXPENSES

Expenses incurred by the Department of HHS and the Department of the Treasury in administering the SMI program and the provisions of the Internal Revenue Code relating to the collection of contributions. Such administrative expenses, which are paid from the SMI trust fund, include expenditures for contractors to determine costs of, and make payments to, providers, as well as salaries and expenses of CMS.

ADMINISTRATIVE LAW JUDGE (ALJ)

A hearings officer who presides over appeal conflicts between providers of services, or beneficiaries, and Medicare contractors.

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.

ADMINISTRATOR

The Administrator of the Centers for Medicare and Medicaid Services.

ADMISSION DATE

The date the patient was admitted for inpatient care, outpatient service, or start of care. For an admission notice for hospice care, enter the effective date of election of hospice benefits.

ADMITTING DIAGNOSIS CODE

Code indicating patient's diagnosis at admission.

ADMITTING PHYSICIAN

The doctor responsible for admitting a patient to a hospital or other inpatient health facility.

ADULT LIVING CARE FACILITY

To be used when billing services rendered at a residential care facility that houses beneficiaries who cannot live alone but who do not need around-the-clock skilled medical services. The facility services do not include a medical component (Program Memo B-98-28).

ADVANCE BENEFICIARY NOTICE (ABN)

A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service from your doctor or supplier, and Medicare does not pay for it, then you probably do not have to pay for it. If the doctor or supplier does give you an ABN that you sign before you get the service, and Medicare does not pay for it, then you will have to pay your doctor or supplier for it. ABN?s only apply if you are in the Original Medicare Plan. They do not apply if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan.

ADVANCE COVERAGE DECISION

A decision that your Private Fee-for-Service Plan makes on whether or not it will pay for a certain service.

ADVANCE DIRECTIVE (HEALTH CARE)

Written ahead of time, a health care advance directive is a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.

ADVANCE DIRECTIVES

A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care.

ADVISORY COUNCIL ON SOCIAL SECURITY

Prior to the enactment of the Social Security Independence and Program Improvements Act of 1994 (Public Law 103-296) on August 15, 1994, the Social Security Act required the appointment of an Advisory Council every 4 years to study and review the financial status of the OASDI and Medicare programs. The most recent Advisory Council was appointed on June 9, 1994, and its report on the financial status of the OASDI program was submitted on January 6, 1997. Under the provisions of Public Law 103-296, this is the last Advisory Council to be appointed.

ADVOCATE

A person who gives you support or protects your rights.

AFFILIATED CONTRACTOR

A Medicare carrier, FI, or other contractor such as a Durable Medical Equipment Regional Carrier (DMERC), which shares some or all of the PSC's jurisdiction in which the affiliated contractor performs non-PSC Medicare functions such as claims processing or education.

AFFILIATED PROVIDER

A health care provider or facility that is paid by a health plan to give service to plan members.

AGED ENROLLEE

An individual aged 65 or over, who is enrolled in the SMI program.

ALBUMIN

One of a class of simple proteins in the blood. The level of albumin may reflect the amount of protein intake in food.

ALGORITHM

Is a rule or procedure containing conditional logic for solving a problem or accomplishing a task. Guideline algorithms concern rules for evaluating patient care against published guidelines. Criteria algorithms concern rules for evaluating criteria compliance. Algorithms may be expresses in written form, graphic outlines, diagrams, flow charts that describe each step in the work or thought process.

ALLOWED CHARGE

Individual charge determined by a carrier for a covered SMI medical service or supply.

AMBULANCE (AIR OR WATER)

An air or water vehicle specifically designed, equipped, and staffed for life saving and transporting the sick or injured.

AMBULANCE (LAND)

A land vehicle specifically designed, equipped, and staffed for life saving and transporting the sick or injured.

AMBULATORY CARE

All types of health services that do not require an overnight hospital stay.

AMBULATORY CARE SENSITIVE CONDITIONS

ACSC stands for Ambulatory Care Sensitive Conditions. ACSC conditions are medical conditions for which physicians broadly concur that a substantial proportion of cases should not advance to the point were hospitalization is needed if they are treated in a timely fashion with adequate primary care and managed properly on an outpatient basis.

AMBULATORY SURGICAL CENTER

A place other than a hospital that does outpatient surgery. At an ambulatory (in and out) surgery center, you may stay for only a few hours or for one night.

AMENDMENTS AND CORRECTIONS

In the final privacy rule, an amendment to a record would indicate that the data is in dispute while retaining the original information, while a correction to a record would alter or replace the original record.

AMERICAN ASSOCIATION FOR HOMECARE

An industry association for the home care industry, including home IV therapy, home medical services and manufacturers, and home health providers. AAHomecare was created through the merger of the Health Industry Distributors Association's Home Care Division (HIDA Home Care), the Home Health Services and Staffing Association (HHSSA), and the National Association for Medical Equipment Services (NAMES).

AMERICAN DENTAL ASSOCIATION

A professional organization for dentists. The ADA maintains a hardcopy dental claim form and the associated claim submission specifications, and also maintains the Current Dental Terminology (CDT ....) medical code set. The ADA and the Dental Content Committee (DeCC), which it hosts, have formal consultative roles under HIPAA.

AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION

An association of health information management professionals. AHIMA sponsors some HIPAA educational seminars.

AMERICAN HOSPITAL ASSOCIATION

A health care industry association that represents the concerns of institutional providers. The AHA hosts the NUBC, which has a formal consultative role under HIPAA.

AMERICAN INSTITUTE OF CERTIFIED PUBLIC ACCOUNTANTS

A national voluntary association of certified public accountants.

AMERICAN MEDICAL ASSOCIATION

A professional organization for physicians. The AMA is the secretariat of the NUCC, which has a formal consultative role under HIPAA. The AMA also maintains the Current Procedural Terminology (CPT ....) medical code set.

AMERICAN MEDICAL INFORMATICS ASSOCIATION

A professional organization that promotes the development and use of medical informatics for patient care, teaching, research, and health care administration.

AMERICAN NATIONAL STANDARDS

Standards developed and approved by organizations accredited by ANSI.

AMERICAN NATIONAL STANDARDS INSTITUTE

An organization that accredits various standards-setting committees, and monitors their compliance with the open rule-making process that they must follow to qualify for ANSI accreditation. HIPAA prescribes that the standards mandated under it be developed by ANSI-accredited bodies whenever practical.

AMERICAN SOCIETY FOR TESTING AND MATERIALS

A standards group that has published general guidelines for the development of standards, including those for health care identifiers. ASTM Committee E31 on Healthcare Informatics develops standards on information used within healthcare.

AMORTIZATION

Process of the gradual retirement of an outstanding debt by making periodic payments to the trust fund.

ANCILLARY SERVICES

Professional services by a hospital or other inpatient health program. These may include x-ray, drug, laboratory, or other services.

ANEMIA

A condition occurring when the blood is deficient in red blood cells and / or hemoglobin which decrease the oxygen carrying capacity of the blood.

ANESTHESIA

Drugs that a person is given before surgery so he or she will not feel pain. Anesthesia should always be given by a doctor or a specially trained nurse.

ANNUAL ELECTION PERIOD

The Annual Election Period for Medicare beneficiaries is the month of November each year. Enrollment will begin the following January. Starting in 2002, this is the only time in which all Medicare+Choice health plans will be open and accepting new members. (See Election Periods.)

APPEAL

An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services or payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if Medicare doesn?t pay for an item or service you think you should be able to get. There is a specific process that your Medicare Advantage Plan or the Original Medicare Plan must use when you ask for an appeal.

APPEAL PROCESS

The process you use if you disagree with any decision about your health care services. If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can have the initial Medicare decision reviewed again. If you are in the Original Medicare Plan, your appeal rights are on the back of the Explanation of Medicare Benefits (EOMB) or Medicare Summary Notice (MSN) that is mailed to you from a company that handles bills for Medicare. If you are in a Medicare managed care plan, you can file an appeal if your plan will not pay for, or does not allow or stops a service that you think should be covered or provided. The Medicare managed care plan must tell you in writing how to appeal. See your plan's membership materials or contact your plan for details about your Medicare appeal rights. (See also Organization Determination.)

APPROVED AMOUNT

The fee Medicare sets as reasonable for a covered medical service. This is the amount a doctor or supplier is paid by you and Medicare for a service or supply. It may be less than the a tual amount charged by a doctor or supplier. The approved amount is sometimes called the "Approved Charge." (See Actual Charge; Assignment.)

AREA AGENCY ON AGING (AAA)

State and local programs that help older people plan and care for their life-long needs. These needs include adult day care, skilled nursing care/therapy, transportation, personal care, respite care, and meals.

ARTICLES

Educational publications/documents that provide coding and coverage guidance on a subject that also may have an associated LCD. Articles may be categorized as:

  • Key articles: Articles designated by the contractor as being associated/pertinent to a specific LCD(s) *Only Found on the MCD Archive Site
  • FAQ: Article developed due to providers frequent inquiries that provide specific information on a particular topic. *Only Found on the MCD Archive Site
  • SAD Exclusion (Self-Administered Drug Exclusion List Article): Articles that list the CPT/HCPCS codes that are excluded from coverage under this category - Self Administered Drug Exclusion Article.
  • Response to Comment (RTC) Articles: Articles that list issues raised by external stakeholders during the Local Coverage Determination comment period.
ASSESSMENT

The gathering of information to rate or evaluate your health and needs, such as in a nursing home.

ASSETS

Treasury notes and bonds guaranteed by the federal government, and cash held by the trust funds for investment purposes.

ASSIGNED CLAIM

A claim submitted for a service or supply by a provider who accepts Medicare assignment.

ASSIGNMENT

In the Original Medicare Plan, this means a doctor agrees to accept the Medicare-approved amount as full payment. If you are in the Original Medicare Plan, it can save you money if your doctor accepts assignment. You still pay your share of the cost of the doctor's visit.

ASSISTED LIVING

A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility. In most cases, the "assisted living" residents pay a regular monthly rent. Then, they typically pay additional fees for the services they get.

ASSOCIATION FOR ELECTRONIC HEALTH CARE TRANSACTIONS

An organization that promotes the use of EDI in the health care industry.

ASSUMPTIONS

Values relating to future trends in certain key factors that affect the balance in the trust funds. Demographic assumptions include fertility, mortality, net immigration, marriage, divorce, retirement patterns, disability incidence and termination rates, and changes in the labor force. Economic assumptions include unemployment, average earnings, inflation, interest rates, and productivity. Three sets of economic assumptions are presented in the Trustees Report:

  1. The low cost alternative, with relatively rapid economic growth, low inflation, and favorable (from the standpoint of program financing) demographic conditions;
  2. The intermediate assumptions, which represent the Trustees' best estimates of likely future economic and demographic conditions; and
  3. The high cost alternative, with slow economic growth, more rapid inflation and financially disadvantageous demographic conditions.

See also Hospital assumptions.

ATTACHMENT(S)

Information, hard copy or electronic, related to a particular claim. Attachments may be structured (such as Certificates of Medical Necessity) or non-structured (such as an Operative Report). Though attachments may be submitted separately, it is common to say the attachment was "submitted with the claim."

ATTENDING PHYSICIAN

Number of the licensed physician who would normally be expected to certify and recertify the medical necessity of the number of services rendered and/or who has primary responsibility for the patient's medical care and treatment.

AUTHORITATIVE APPROVAL

Method or type of approval that requires a determination that the service is likely to have a diagnostic or therapeutic benefit for patients for whom it is intended.

AUTHORITATIVE EVIDENCE

Written medical or scientific conclusions demonstrating the medical effectiveness of a service produced by the following:

  • Controlled clinical trials, published in peer-reviewed medical or scientific journals;
  • Controlled clinical trials completed and accepted for publication in peer-reviewed medical or scientific journals;
  • Assessments initiated by CMS;
  • Evaluations or studies initiated by Medicare contractors;
  • Case studies published in peer-reviewed medical or scientific journals that present treatment protocols.
AUTHORIZATION

MCO approval necessary prior to the receipt of care. (Generally, this is different from a referral in that, an authorization can be a verbal or written approval from the MCO whereas a referral is generally a written document that must be received by a doctor before giving care to the beneficiary.)

AUTOMATED CLAIM REVIEW

Claim review and determination made using system logic (edits). Automated claim reviews never require the intervention of a human to make a claim determination.

AVERAGE MARKET YIELD

A computation that is made on all marketable interest-bearing obligations of the United States. It is computed on the basis of market quotations as of the end of the calendar month immediately preceding the date of such issue.


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Term Definition
BABY BOOM

The period from the end of World War II through the mid-1960s marked by unusually high birth rates.

BALANCE BILLING

A situation in which Private Fee-for-Service Plan providers (doctors or hospitals) can charge and bill you 15% more than the plan's payment amount for services.

BASE ESTIMATE

The updated estimate of the most recent historical year.

BASIC BENEFITS

Basic Benefits includes both Medicare-covered benefits (except hospice services) and additional benefits.

BASIC BENEFITS (MEDIGAP POLICY)

Benefits provided in Medigap Plan A. They are also included in all other standardized Medigap policies. (See Medigap Policy.)

BENCHMARK

A benchmark is sustained superior performance by a medical care provider, which can be used as a reference to raise the mainstream of care for Medicare beneficiaries. The relative definition of superior will vary form situation to situation. In many instances an appropriate benchmark would be a provider that appears in the top 10% of all providers for more than a year.

BENEFICIARY

The name for a person who has health care insurance through the Medicare or Medicaid program.

BENEFICIARY ENCRYPTED FILE

A restricted public use file. An Agreement for Release of the Centers for Medicare & Medicaid (CMS) Beneficiary Encrypted Files (PDF, 13KB) data use agreement is required.

BENEFICIARY NOTIFICATION LETTER

A letter that is required with CMS Administrator's signature when Medicare beneficiaries will be contacted to participate in a research project.

BENEFIT PAYMENTS

The amounts disbursed for covered services to beneficiaries after the deductible and coinsurance amounts have been deducted.

BENEFIT PERIOD

The way that Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven?t received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into the hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins if you are in the Original Medicare Plan. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

BENEFITS

The money or services provided by an insurance policy. In a health plan, benefits are the health care you get.

BENEFITS DESCRIPTION (PLAN)

The scope, terms and/or condition(s) of coverage including any limitation(s) associated with the plan provision of the service.

BIOLOGICALS

Usually a drug or vaccine made from a live product and used medically to diagnose, prevent, or treat a medical condition. For example, a flu or pneumonia shot.

BIOMETRIC IDENTIFIER

An identifier based on some physical characteristic, such as a fingerprint.

BIRTHING CENTER

A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of new born infants.

BLOOD UREA NITROGEN

The term BUN refers to the substance urea, which is the major breakdown product of protein metabolism, and is ordinarily removed by the kidneys. During kidney failure, ure accumulates in proportion to the degree of kidney failure and to the amount of protein breakdown. The symptoms of uremia correspond roughly to the amount of urea in the blood stream.

BLUE CROSS AND BLUE SHIELD ASSOCIATION

An association that represents the common interests of Blue Cross and Blue Shield health plans. The BCBSA serves as the administrator for the Health Care Code Maintenance Committee and also helps maintain the HCPCS Level II codes.

BOARD AND CARE HOME

A type of group living arrangement designed to meet the needs of people who cannot live on their own. These homes offer help with some personal care services.

BOARD HEARING

That hearing provided for in section 1878(a) of the Act (42 U.S.C. 139500(a)) and 42 CFR 405.1835.

BOARD OF TRUSTEES

A Board established by the Social Security Act to oversee the financial operations of the Federal Supplementary Medical Insurance Trust Fund. The Board is composed of six members, four of whom serve automatically by virtue of their positions in the federal government: the Secretary of the Treasury, who is the Managing Trustee; the Secretary of Labor; the Secretary of Health and Human Services; and the Commissioner of Social Security. The other two members are appointed by the President and confirmed by the Senate to serve as public representatives. John L. Palmer and Thomas R. Saving began serving their 4-year terms on October 28, 2000. The Administrator of CMS serves as Secretary of the Board of Trustees.

BOARD-CERTIFIED

This means a doctor has special training in a certain area of medicine and has passed an advanced exam in that area of medicine. Both primary care doctors and specialists may be board-certified.

BODY RECORD

The body or data record contains information on a single OASIS-B1 patient assessment.

BOND

A certificate of ownership of a specified portion of a debt due by the federal government to holders, bearing a fixed rate of interest.

BONUS

Means a payment a physician or entity receives beyond any salary, fee-for-service payments, capitation or returned withhold. Bonuses and other compensation that are not based on referral or utilization levels (such as bonuses based solely on quality of care, patient satisfaction or physician participation on a committee) are not considered in the calculation of substantial financial risk.

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 MODEL

A model of a business organization or process.

BUSINESS PARTNER

See Business Associate.

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
CADAVERIC TRANSPLANT

The surgical procedure of excising a kidney from a deceased individual and implanting it into a suitable recipient.

CALLABLE

Subject to redemption upon notice, as is a bond.

CAPITATION

A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member's health care services for a certain length of time.

CAPPED RENTAL ITEM

Durable medical equipment (like nebulizers or manual wheelchairs) that costs more than $150, and the supplier rents it to people with Medicare more than 25 percent of the time.

CARE PLAN

A written plan for your care. It tells what services you will get to reach and keep your best physical, mental, and social well being.

CAREGIVER

A person who helps care for someone who is ill, disabled, or aged. Some caregivers are relatives or friends who volunteer their help. Some people provide caregiving services for a cost.

CARRIER

A private company that has a contract with Medicare to pay your Medicare Part B bills. (See Medicare Part B.)

CASE MANAGEMENT

A process used by a doctor, nurse, or other health professional to manage your health care. Case managers make sure that you get needed services, and track your use of facilities and resources.

CASE MANAGER

A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.

CASE MIX

Is the distribution of patients into categories reflecting differences in severity of illness or resource consumption.

CASE MIX INDEX

The average DRG relative weight for all Medicare admissions.

CASH BASIS

The costs of the service when payment was made rather than when the service was performed.

CATASTROPHIC ILLNESS

A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause you financial hardship.

CATASTROPHIC LIMIT

The highest amount of money you have to pay out of your pocket during a certain period of time for certain covered charges. Setting a maximum amount you will have to pay protects you.

CENTER FOR HEALTHCARE INFORMATION MANAGEMENT

A health information technology industry association.

CENTERS FOR DISEASE CONTROL AND PREVENTION

An organization that maintains several code sets included in the HIPAA standards, including the ICD-9-CM codes.

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.

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

CENTERS FOR MEDICARE & MEDICAID SERVICES DATA CENTER USER FORM

A form that is required for access to the CMS data center.

CERTIFICATE OF INDEBTEDNESS

A short-term certificate of ownership (12 months or less) of a specified portion of a debt due by the federal government to individual holders, bearing a fixed rate of interest.

CERTIFICATE OF MEDICAL NECESSITY

A form required by Medicare that allows you to use certain durable medical equipment prescribed by your doctor or one of the doctor?s office staff.

CERTIFIED (CERTIFICATION)

This means a hospital has passed a survey done by a State government agency. Being certified is not the same as being accredited. Medicare only covers care in hospitals that are certified or accredited.

CERTIFIED NURSING ASSISTANT (CNA)

CNAs are trained and certified to help nurses by providing non-medical assistance to patients, such as help with bathing, dressing, and using the bathroom.

CERTIFIED REGISTERED NURSE ANESTHETIST

A nurse who is trained and licensed to give anesthesia. Anesthesia is given before and during surgery so that a person does not feel pain. (See Anesthesia.)

CHAIN OF TRUST

A term used in the HIPAA Security NPRM for a pattern of agreements that extend protection of health care data by requiring that each covered entity that shares health care data with another entity require that that entity provide protections comparable to those provided by the covered entity, and that that entity, in turn, require that any other entities with which it shares the data satisfy the same requirements.

CHAIN OF TRUST AGREEMENT

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

CHRONIC MAINTENANCE DIALYSIS

Dialysis that is regularly furnished to an ESRD patient in a hospital based independent (non-hospital based), or home setting.

CIVILIAN HEALTH AND MEDICAL PROGRAM (CHAMPUS)

Run by the Department of Defense, in the past CHAMPUS gave medical care to active duty members of the military, military retirees, and their eligible dependents. (This program is now called "TRICARE")

CLAIM

A claim is a request for payment for services and benefits you received. Claims are also called bills for all Part A and Part B services billed through Fiscal Intermediaries. "Claim" is the word used for Part B physician/supplier services billed through the Carrier. (See Carrier; Fiscal Intermediaries; Medicare Part A; Medicare Part B.)

CLAIM ADJUSTMENT REASON CODES

A national administrative code set that identifies the reasons for any differences, or adjustments, between the original provider charge for a claim or service and the payer's payment for it. This code set is used in the X12 835 Claim Payment & Remittance Advice and the X12 837 Claim transactions, and is maintained by the Health Care Code Maintenance Committee.

CLAIM ATTACHMENT

Any of a variety of hardcopy forms or electronic records needed to process a claim in addition to the claim itself.

CLAIM STATUS CATEGORY CODES

A national administrative code set that indicates the general category of the status of health care claims. This code set is used in the X12 277 Claim Status Notification transaction, and is maintained by the Health Care Code Maintenance Committee.

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.

CLINICAL BREAST EXAM

An exam by your doctor/health care provider to check for breast cancer by feeling and looking at your breasts. This exam is not the same as a mammogram and is usually done in the doctor's office during your Pap test and pelvic exam.

CLINICAL PERFORMANCE MEASURE

This is a method or instrument to estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality.

CLINICAL PRACTICE GUIDELINES

Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.

CLINICAL TRIALS

Clinical trials are one of the final stages of a long and careful research process to help patients live longer, healthier lives. They help doctors and researchers find better ways to prevent, diagnose, or treat diseases. Clinical trials test new types of medical care, like how well a new cancer drug works. The trials help doctors and researchers see if the new care works and if it is safe. They may also be used to compare different treatments for the same condition to see which treatment is better, or to test new uses for treatments already in use.

CMS AGENT

Any individual or organization, public or private, with whom CMS has a contractual arrangement to contribute to or participate in the Medicare survey and certification process. The State survey agency is the most common example of a "CMS" agent as established through the partnership role of the State agency (SA) plays in the survey process under the provisions of 1864 of the Act. A private physician serving a contractual consultant role with the SA or CMS regional office as part of a survey and certification activity is another example of a "CMS agent".

CMS DIRECTED IMPROVEMENT PROCESS

A CMS directed improvement project is any project where CMS specifies the subject, size, pace, data source, analytic techniques, educational intervention techniques, or impact measurement model. These projects may be developed by CMS in consultation with Networks, the health care community, and other interested people.

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.

CODE SET MAINTAINING ORGANIZATION

Under HIPAA, this is an organization that creates and maintains the code sets adopted by the Secretary for use in the transactions for which standards are adopted. Also see Part II, 45 CFR 162.103.

COGNITIVE IMPAIRMENT

A breakdown in a person's mental state that may affect a person's moods, fears, anxieties, and ability to think clearly.

COHORT

A population group that shares a common property, characteristic, or event, such as a year of birth or year of marriage. The most common one is the birth cohort, a group of individuals born within a defined time period, usually a calendar year or a five-year interval.

COINSURANCE (MEDICARE PRIVATE FEE-FOR-SERVICE PLAN)

The percentage of the Private Fee-for-Service Plan charge for services that you may have to pay after you pay any plan deductibles. In a Private Fee-for-Service Plan, the coinsurance payment is a percentage of the cost of the service (like 20%).

COINSURANCE (OUTPATIENT PROSPECTIVE PAYMENT SYSTEM)

The percentage of the Medicare payment rate or a hospital's billed charge that you have to pay after you pay the deductible for Medicare Part B services.

COLLEGE OF HEALTHCARE INFORMATION MANAGEMENT EXECUTIVES

A professional organization for health care Chief Information Officers (CIOs).

COMMENT

Public commentary on the merits or appropriateness of proposed or potential regulations provided in response to an NPRM, an NOI, or other federal regulatory notice.

COMMERCIAL MCO

A Commercial MCO is a health maintenance organization, an eligible organization with a contract under 1876 or a Medicare-Choice organization; a provider sponsored organization, or any other private or public organization, which meets the requirements of 1902(w). These MCOs provide comprehensive services to commercial and/or Medicare enrollees, as well as Medicaid enrollees.

COMMUNITY MENTAL HEALTH CENTER

A facility that provides the following services:

  • Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharge from inpatient treatment at a mental health facility,
  • 24 hour a day emergency care services,
  • Day treatment, other than partial hospitalization services, or psychosocial rehabilitation services,
  • Screening for patients considered for admission to State mental health facilities to determine the appropriateness of such admission, and
  • Consultation and education services.
COMPLAINT

(See Grievance.)

COMPLAINT (OF FRAUD OR ABUSE)

A statement, oral or written, alleging that a provider or beneficiary received a Medicare benefit of monetary value, directly or indirectly, overtly or covertly, in cash or in kind, to which he or she is not entitled under current Medicare law, regulations, or policy. Included are allegations of misrepresentation and violations of Medicare requirements applicable to persons or entities that bill for covered items and services.

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.

COMPREHENSIVE INPATIENT REHABILITATION FACILITY

A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.

COMPREHENSIVE MCO

A MCO is a health maintenance organization, an eligible organization with a contract under 1876 or a Medicare-Choice organization; a provider sponsored organization or any other private or public organization, which meets the requirements of 1902(w). These MCOs provides comprehensive services to both commercial and/or Medicare, as well as Medicaid enrollees.

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY

A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF)

A facility that provides a variety of services including physicians' services, physical therapy, social or psychological services, and outpatient rehabilitation.

COMPUTER MATCHING AGREEMENT

Any computerized comparison of two or more systems of records or a system of records of non-Federal records for the purpose of (1) establishments or verifying eligibility or compliance with law and regulations of applicants or recipients/beneficiaries, or (2) recouping payments or overpayments.

COMPUTER-BASED PATIENT RECORD INSTITUTE-HEALTHCARE OPEN SYSTEMS AND TRIALS

An industry organization that promotes the use of healthcare information systems, including electronic healthcare records.

CONDITIONAL PAYMENT

A payment made by Medicare for services for which another payer is responsible.

CONFIDENTIALITY

Your right to talk with your health care provider without anyone else finding out what you have said.

CONSENT AND AUTHORIZATION (BASIC RULE)

A covered entity may use or disclose PHI only:

  • With the consent of the individual for treatment, payment, or health care operations;
  • With the authorization of the individual for all other uses or disclosures;
  • As permitted under this rule for certain public policy purposes.
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)*

A law that lets some people keep their employer group health plan coverage for a period of time after: the death of your spouse, losing your job, having your working hours reduced, leaving your job voluntarily, or getting a divorce. You may have to pay both your share and the employer?s share of the premium. Generally, you also have to pay an administrative fee.

CONSUMER ASSESSMENT OF HEALTH PLANS STUDY (CAHPS)

An annual nationwide survey that is used to report information on Medicare beneficiaries' experiences with managed care plans. The results are shared with Medicare beneficiaries and the public.

CONSUMER PRICE INDEX

A measure of the average change in prices over time in a fixed group of goods and services. In this report, all references to the CPI relate to the CPI for Urban Wage Earners and Clerical Workers (CPI-W).

CONSUMER SELF-REPORT DATA

Data collected through survey or focus group. Surveys may include Medicaid beneficiaries currently or previously enrolled in a MCO or PHP. The survey may be conducted by the State or a contractor to the State.

CONSUMER SURVEY DATA

Data collected through a survey of those Medicaid beneficiaries who are enrolled in the program and have used the services. The survey may be conducted by the State or by the managed care entity (if the managed care entity reports the results to the State).

CONTINGENCY

Funds included in the trust fund to serve as a cushion in case actual expenditures are higher than those projected at the time financing was established. Since the financing is set prospectively, actual experience may be different from the estimates used in setting the financing.

CONTINGENCY MARGIN

An amount included in the actuarial rates to provide for changes in the contingency level in the trust fund. Positive margins increase the contingency level, and negative margins decrease it.

CONTINUATION OF ENROLLMENT

Allows MCOs to offer enrollees the option of continued enrollment in the M+C plan when enrollees leave the plan?s service area to reside elsewhere. CMS has interpreted this to be on a permanent basis. M+C Organizations that choose the continuation of enrollment option must explain it in marketing materials and make it available to all enrollees in the service area. Enrollees may choose to exercise this option when they move or they may choose to disenroll.

CONTINUING CARE RETIREMENT COMMUNITY (CCRC)

A housing community that provides different levels of care based on what each resident needs over time. This is sometimes called "life care" and can range from independent living in an apartment to assisted living to full-time care in a nursing home. Residents move from one setting to another based on their needs but continue to live as part of the community. Care in CCRCs is usually expensive. Generally, CCRCs require a large payment before you move in and charge monthly fees.

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS

A type of dialysis where the patient's peritoneal membrane is used as the dialyzer. The patient dialyzes at home, using special supplies, but without the need for a machine (see peritoneal dialysis).

CONTINUOUS CYCLING PERITONEAL DIALYSIS

A type of dialysis where the patient generally dialyzes at home and utilizes an automated peritoneal cycler for delivering dialysis exchanges (see peritoneal dialysis).

CONTINUOUS QUALITY IMPROVEMENT

A process which continually monitors program performance. When a quality problem is identified, CQI develops a revised approach to that problem and monitors implementation and success of the revised approach. The process includes involvement at all stages by all organizations, which are affected by the problem and/or involved in implementing the revised approach.

CONTRACTOR

An entity that has an agreement with CMS or another funding agency to perform a project.

CONTRACTOR POLICY

Policy developed by CMS Contractors (PSC, AC, FI, or carrier) and used to make coverage and coding determinations. It is developed when:

  • there is an absence of national coverage policy for a service or all of the uses of a service;
  • there is a need to interpret national coverage policy; or
  • local coding rules are needed.
CONTRIBUTION BASE

See "Maximum tax base."

CONTRIBUTIONS

See "Payroll taxes."

COORDINATED CARE PLAN

A plan that includes a CMS-approved network of providers that are under contract or arrangement with the M+C organization to deliver the benefit package approved by CMS. Coordinated care plans include plans offered by health maintenance organizations (HMOs), provider-sponsored organizations (PSOs), preferred provider organizations (PPOs), as well as other types of network plans (except network MSA plans. See 42 C.F.R. 422.4(a)(1).

COORDINATION OF BENEFITS

A program that determines which plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits. If one of the plans is a Medicare health plan, Federal law may decide who pays first.

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.

COORDINATION PERIOD

A period of time when your employer group health plan will pay first on your health care bills and Medicare will pay second. If your employer group health plan doesn't pay 100% of your health care bills during the coordination period, Medicare may pay the remaining costs.

COST RATE

The ratio of the cost (or outgo, expenditures, or disbursements) of the program on an incurred basis during a given year to the taxable payroll for the year. In this context, the outgo is defined to exclude benefit payments and administrative costs for those uninsured persons for whom payments are reimbursed from the general fund of the Treasury, and for voluntary enrollees, who pay a premium to be enrolled.

COST REPORT

The report required from providers on an annual basis in order to make a proper determination of amounts payable under the Medicare program.

COST SHARING

The cost for medical care that you pay yourself like a copayment, coinsurance, or deductible. (See Coinsurance; Copayment; Deductible.)

COST-BASED HEALTH MAINTENANCE ORGANIZATION

A type of managed care organization that will pay for all of the enrollees/members' medical care costs in return for a monthly premium, plus any applicable deductible or co-payment. The HMO will pay for all hospital costs (generally referred to as Part A) and physician costs (generally referred to as Part B) that it has arranged for and ordered. Like a health care prepayment plan (HCPP), except for out-of-area emergency services, if a Medicare member/enrollee chooses to obtain services that have not been arranged for by the HMO, he/she is liable for any applicable deductible and co-insurance amounts, with the balance to be paid by the regional Medicare intermediary and/or carrier.

COVERAGE ANALYSIS FOR LABORATORIES (CALS)

CALs is an abbreviated process, similar to the NCD process, for making changes to the coding component of the negotiated laboratory NCDs. The process is used for adjusting the list of covered (or non-covered) ICD-9-CM diagnosis codes and coding guidance in the NCDs when there is a question regarding whether the code flows from the narrative indications in the NCD. A tracking sheet is posted opening a CAL and a 30-day public comment period follows. A decision memorandum announcing and explaining the decision is posted following the comment period. Changes are implemented in the next available quarterly update of the laboratory edit module. More details regarding the process can be found in 68 FR 74607.

COVERAGE BASIS

The M+C Plan charge schedule used to base the maximum dollar coverage or coinsurance level for a service category (e.g., a $500 annual coverage limit for a prescription drug benefit may be based on a Published Retailed Price schedule, or 20% coinsurance for DME benefit may be based on a Medicare FFS fee schedule).

COVERAGE ISSUES MANUAL (CIM)

The CIM has been replaced by the Medicare National Coverage Determinations Manual.

COVERED BENEFIT

A health service or item that is included in your health plan, and that is paid for either partially or fully.

COVERED CHARGES

Services or benefits for which a health plan makes either partial or full payment.

COVERED EARNINGS

Earnings in employment covered by the HI program.

COVERED EMPLOYMENT

All employment and self-employment creditable for Social Security purposes. Almost every kind of employment and self-employment is covered under the program. In a few employment situations-for example, religious orders under a vow of poverty, foreign affiliates of American employers, or the employer must elect State and local governments-coverage. However, effective July 1991, coverage is mandatory for State and local employees who are not participating in a public employee retirement system. All new State and local employees have been covered since April 1986. In a few situations-for instance, ministers or self-employed members of certain religious groups-workers can opt out of coverage. Covered employment for HI includes all federal employees (whereas covered employment for OASDI includes some, but not all, federal employees).

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.

COVERED FUNCTION

Functions that make an entity a health plan, a health care provider, or a health care clearinghouse.

COVERED SERVICES

Services for which SMI pays, as defined and limited by statute. Covered services include most physician services, care in outpatient departments of hospitals, diagnostic tests, DME, ambulance services, and other health services that are not covered by the HI program.

COVERED WORKER

A person who has earnings creditable for Social Security purposes on the basis of services for wages in covered employment and/or on the basis of income from covered self-employment. The number of HI covered workers is slightly larger than the number of OASDI covered workers because of different coverage status for federal employment. See "Covered employment."

CREDITABLE COVERAGE

Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period. (See Pre-existing Conditions.)

CRITERIA

The expected levels of achievement or specifications against which performance can be assessed.

CRITICAL ACCESS HOSPITAL

A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.

CROSSWALKING

A new test is determined to be similar to an existing test, multiple existing test codes, or a portion of an existing test code. The new test code is then assigned the related existing local fee schedule amounts and resulting national limitation amount. In some instances, a test may only equate to a portion of a test, and, in those instances, payment at an appropriate percentage of the payment for the existing test is assigned.

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.

CUSTODIAL CARE

Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving round, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn?t pay for custodial care.

CUSTODIAL CARE FACILITY

A facility, which provides room, board, and other personal assistance services, generally on a long-term basis and which does not include a medical component.

CUSTODIAN

The person responsible for the security and safeguard of CMS data for the duration of the project.


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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 COUNCIL

A coordinating body within HHS that has high-level responsibility for overseeing the implementation of the A/S provisions of HIPAA.

DATA DICTIONARY

A document or system that characterizes the data content of a system.

DATA ELEMENT

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

DATA EXTRACT SYSTEM ACCESS FORM

A form that is required for access to the DESY system. This system replaces the Data Support Access Facility (DSAF).

DATA INTERCHANGE STANDARDS ASSOCIATION

A body that provides administrative services to X12 and several other standards-related groups.

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.

DATA MODEL

A conceptual model of the information needed to support a business function or process.

DATA SUPPORT ACCESS FACILITY ACCESS FORM

A form that is required for access to Leg 1 (Enrollment Database (EDB)) and, Leg 2 (Medicare Provider Analysis and Review(MEDPAR)) of the Data Support Access Facility.

DATA USE AGREEMENT

Legal binding agreement which CMS requires to obtain identifiable data. It also delineates the confidentiality requirements of the Privacy Act of 1974 security safeguards, and CMS's data use policy and procedures.

DATA USE CHECKLIST

A form used to provide pertinent information about the data request and identifies the identifiable data being processed.

DATE OF FILING AND DATE OF SUBMISSION

The day of the mailing (as evidenced by the postmark) or hand-delivery of materials, unless otherwise defined.

DATE OF RECEIPT

The date on the return receipt of "return receipt requested" mail, unless otherwise defined.

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.

DEDUCTIBLE (MEDICARE)

The amount you must pay for health care before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B. These amounts can change every year. (See Benefit Period; Medicare Part A; Medicare Part B.)

DEEMED

Providers are ?deemed? when they know, before providing services, that you are in a Private Fee-for-Service Plan, and they agree to give you care. Providers that are ?deemed? agree to follow your plan?s terms and conditions of payment for the services you get.

DEEMED STATUS

Designation that an M+C organization has been reviewed and determined "fully accredited" by a HCFA-approved accrediting organization for those standards within the deeming categories that the accrediting organization has the authority to deem.

DEEMED WAGE CREDIT

See "Non-contributory or deemed wage credits."

DEEMING AUTHORITY

The authority granted by CMS to accrediting organizations to determine, on CMS's behalf, whether a M+CO evaluated by the accrediting organization is in compliance with corresponding Medicare regulations.

DEFICIENCY (NURSING HOME)

A finding that a nursing home failed to meet one or more federal or state requirements.

DEHYDRATION

A serious condition where your body's loss of fluid is more than your body's intake of fluid.

DEMOGRAPHIC ASSUMPTIONS

See Assumptions.

DEMOGRAPHIC DATA

Data that describe the characteristics of enrollee populations within a managed care entity. Demographic data include but are not limited to age, sex, race/ethnicity, and primary language.

DEMONSTRATIONS

Projects and contracts that CMS has signed with various health care organizations. These contracts allow CMS to test various or specific attributes such as payment methodologies, preventive care, social care, etc., and to determine if such projects/pilots should be continued or expanded to meet the health care needs of the Nation. Demonstrations are used to evaluate the effects and impact of various health care initiatives and the cost implications to the public.

DENTAL CONTENT COMMITTEE

An organization, hosted by the American Dental Association, that maintains the data content specifications for dental billing. The Dental Content Committee has a formal consultative role under HIPAA for all transactions affecting dental health care services.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

DHHS administers many of the "social" programs at the Federal level dealing with the health and welfare of the citizens of the United States. (It is the "parent" of CMS.)

DERIVATIVE FILE

A subset from an original identifiable file.

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 DATA CONTENT COMMITTEE OR DESIGNATED DCC

An organization which HHS has designated for oversight of the business data content of one or more of the HIPAA-mandated transaction standards.

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.

DETERMINATION

A decision made to either pay in full, pay in part, or deny a claim. (See also Initial Claim Determination.)

DIABETIC DURABLE MEDICAL EQUIPMENT

Purchased or rented ambulatory items, such a glucose meters and insulin infusion pumps, prescribed by a health care provider for use in managing a patient's diabetes, as covered by Medicare.

DIAGNOSIS

The name for the health problem that you have.

DIAGNOSIS CODE

The first of these codes is the ICD-9-CM diagnosis code describing the principal diagnosis (i.e. The condition established after study to be chiefly responsible for causing this hospitalization). The remaining codes are the ICD-9-CM diagnosis codes corresponding to additional conditions that coexisted at the time of admission, or developed subsequently, and which had an effect on the treatment received or the length of stay.

DIAGNOSIS-RELATED GROUPS

A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual.

DIALYSATE

Dialysate or the dialysate fluid is the solution used in dialysis to remove excess fluids and waste products from the blood.

DIALYSIS

A process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semi-permeable membrane. The two types of dialysis that are currently commonly in use are hemodialysis and peritoneal dialysis.

DIALYSIS

Dialysis is a treatment that cleans your blood when your kidneys don?t work. It gets rid of harmful wastes and extra salt and fluids that build up in your body. It also helps control blood pressure and helps your body keep the right amount of fluids. Dialysis treatments help you feel better and live longer, but they are not a cure for permanent kidney failure (See hemodialysis and peritoneal dialysis.).

DIALYSIS CENTER (RENAL)

A hospital unit that is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of the ESRD dialysis patients (including inpatient dialysis) furnished directly or under arrangement.

DIALYSIS FACILITY (RENAL)

A unit (hospital based or freestanding) which is approved to furnish dialysis services directly to ESRD patients.

DIALYSIS STATION

A portion of the dialysis patient treatment area which accommodates the equipment necessary to provide a hemodialysis or peritoneal dialysis treatment. This station must have sufficient area to house a chair or bed, the dialysis equipment, and emergency equipment if needed. Provision for privacy is ordinarily supplied by drapes or screens.

DIETHYLSTILBESTROL (DES)

A drug given to pregnant women from the early 1940s until 1971 to help with common problems during pregnancy. The drug has been linked to cancer of the cervix or vagina in women whose mother took the drug while pregnant.

DIGITAL IMAGING AND COMMUNICATIONS IN MEDICINE

A standard for communicating images, such as x-rays, in a digitized form. This standard could become part of the HIPAA claim attachments standards.

DIRECT DATA ENTRY

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

DISABILITY

For Social Security purposes, the inability to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or to last for a continuous period of not less than 12 months. Special rules apply for workers aged 55 or older whose disability is based on blindness. The law generally requires that a person be disabled continuously for 5 months before he or she can qualify for a disabled worker cash benefit. An additional 24 months is necessary to qualify under Medicare.

DISABILITY INSURANCE

See "Old-Age, Survivors, and Disability Insurance (OASDI)."

DISABLED ENROLLEE

An individual under age 65 who has been entitled to disability benefits under Title II of the Social Security Act or the Railroad Retirement system for at least 2 years and who is enrolled in the SMI program.

DISCHARGE PLANNING

A process used to decide what a patient needs for a smooth move from one level of care to another. This is done by a social worker or other health care professional. It includes moves from a hospital to a nursing home or to home care. Discharge planning may also include the services of home health agencies to help with the patient's home care.

DISCLOSURE

Release or divulgence of information by an entity to persons or organizations outside of that entity.

DISCLOSURE HISTORY

Under HIPAA this is a list of any entities that have received personally identifiable health care information for uses unrelated to treatment and payment.

DISCOUNT DRUG LIST

A list of certain drugs and their proper dosages. The discount drug list includes the drugs the company will discount.

DISCRETIONARY SPENDING

Outlays of funds subject to the Federal appropriations process.

DISENROLL

Ending your health care coverage with a health plan.

DISPROPORTIONATE SHARE HOSPITAL

A hospital with a disproportionately large share of low-income patients. Under Medicaid, States augment payment to these hospitals. Medicare inpatient hospital payments are also adjusted for this added burden.

DOWNCODE

Reduce the value and code of a claim when the documentation does not support the level of service billed by a provider.

DRAFT STANDARD FOR TRIAL USE

An archaic term for any X12 standard that has been approved since the most recent release of X12 American National Standards. The current equivalent term is "X12 standard".

DRG CODING

The DRG categories used by hospitals on discharge billing. See also "Diagnosis-related groups (DRGs)."

DRUG TIERS

Drug tiers are definable by the plan. The option "tier" was introduced in the PBP to allow plans the ability to group different drug types together (i.e., Generic, Brand, Preferred Brand). In this regard, tiers could be used to describe drug groups that are based on classes of drugs. If the "tier" option is utilized, plans should provide further clarification on the drug type(s) covered under the tier in the PBP notes section(s). This option was designed to afford users additional flexibility in defining the prescription drug benefit.

DUAL ELIGIBLES

Persons who are entitled to Medicare (Part A and/or Part B) and who are also eligible for Medicaid.

DURABLE MEDICAL EQUIPMENT

Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs, and other medically necessary equipment prescribed by a health care provider to be used in a patient's home which are covered by Medicare.

DURABLE MEDICAL EQUIPMENT

Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.

DURABLE MEDICAL EQUIPMENT (DME)

Medical equipment that is ordered by a doctor (or, if Medicare allows, a nurse practitioner, physician assistant or clinical nurse specialist) for use in the home. A hospital or nursing home that mostly provides skilled care can?t qualify as a ?home? in this situation. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.

DURABLE MEDICAL EQUIPMENT MEDICARE ADMINISTRATIVE CONTRACTOR (DME MAC)

Medicare Part B contractor responsible for administering durable medical equipment benefits in a specific jurisdiction.

DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER (DMERC)

A Medicare contractor that was responsible for administering Durable Medical Equipment (DME) benefits for a region. The term DME MAC has replaced the term DMERC.

DURABLE POWER OF ATTORNEY

A legal document that enables you to designate another person, called the attorney-in-fact, to act on your behalf, in the event you become disabled or incapacitated.


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Term Definition
EARNINGS

Unless otherwise qualified, all wages from employment and net earnings from self-employment, whether or not taxable or covered.

ECONOMIC ASSUMPTIONS

See "Assumptions."

ECONOMIC STABILIZATION PROGRAM

A legislative program during the early 1970s that limited price increases.

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.

EDIT

Logic within the Standard Claims Processing System (or PSC Supplemental Edit Software) that selects certain claims, evaluates or compares information on the selected claims or other accessible source, and depending on the evaluation, takes action on the claims, such as pay in full, pay in part, or suspend for manual review.

EFFECTIVE

Producing the expected results of this SOW, defined in section 1.B., Purpose of Contract.

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.

EFFICIENT

Activities performed effectively with minimum of waste or unnecessary effort, or producing a high ratio of results to resources.

ELDERCARE

Public, private, formal, and informal programs and support systems, government laws, and finding ways to meet the needs of the elderly, including: housing, home care, pensions, Social Security, long-term care, health insurance, and elder law.

ELECTION

Your decision to join or leave the Original Medicare Plan or a Medicare+Choice plan.

ELECTION PERIODS

Time when an eligible person may choose to join or leave the Original Medicare Plan or a Medicare+Choice plan. There are four types of election periods in which you may join and leave Medicare health plans: Annual Election Period, Initial Coverage Election Period, Special Election Period, and Open Enrollment Period.

  • Annual Election Period: The Annual Election Period is the month of November each year. Medicare health plans enroll eligible beneficiaries into available health plans during the month of November each year. Starting in 2002, this is the only time in which all Medicare+Choice health plans will be open and accepting new members.
  • Initial Coverage Election Period: The three months immediately before you are entitled to Medicare Part A and enrolled in Part B. If you choose to join a Medicare health plan during your Initial Coverage Election Period, the plan must accept you. The only time a plan can deny your enrollment during this period is when it has reached its member limit. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP).
  • Special Election Period: You are given a Special Election Period to change Medicare+Choice plans or to return to Original Medicare in certain situations, which include: You make a permanent move outside the service area, the Medicare+Choice organization breaks its contract with you or does not renew its contract with CMS; or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP).
  • Open Enrollment Period: If the Medicare health plan is open and accepting new members, you may join or enroll in it. If a health plan chooses to be open, it must allow all eligible beneficiaries to join or enroll.
ELECTRONIC COMMERCE

The exchange of business information by electronic means.

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 HEALTHCARE NETWORK ACCREDITATION COMMISSION

An organization that tests transactions for consistency with the HIPAA requirements, and that accredits health care clearinghouses.

ELECTRONIC MEDIA CLAIMS

This term usually refers to 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 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 MEDIA QUESTIONNAIRE

A process that large employers can use to complete their requirements for supplying IRS/SSA/HCFA Data Match information electronically.

ELECTRONIC REMITTANCE ADVICE

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

ELIGIBILITY

Refers to the process whereby an individual is determined to be eligible for health care coverage through the Medicaid program. Eligibility is determined by the State. Eligibility data are collected and managed by the State or by its Fiscal Agent. In some managed care waiver programs, eligibility records are updated by an Enrollment Broker, who assists the individual in choosing a managed care plan to enroll in.

ELIGIBILITY/MEDICARE PART A

You are eligible for premium-free (no cost) Medicare Part A (Hospital Insurance) if:

  • You are 65 or older and you are receiving, or are eligible for, retirement benefits from Social Security or the Railroad Retrirement Board, or
  • You are under 65 and you have received Railroad Retirement disability benefits for the prescribed time and you meet the Social Security Act disability requirements, or
  • You or your spouse had Medicare-covered government employment, or
  • You are under 65 and have End-Stage Renal Disease (ESRD).

If you are not eligible for premium-free Medicare Part A, you can buy Part A by paying a monthly premium if:

  • You are age 65 or older, and
  • You are enrolled in Part B, and
  • You are a resident of the United States, and are either a citizen or an alien lawfully admitted for permanent residence who has lived in the United States continuously during the 5 years immediately before the month in which you apply.
ELIGIBILITY/MEDICARE PART B

You are automatically eligible for Part B if you are eligible for premium-free Part A. You are also eligible for Part B if you are not eligible for premium-free Part A, but are age 65 or older AND a resident of the United States or a citizen or an alien lawfully admitted for permanent residence. In this case, you must have lived in the United States continuously during the 5 years immediately before the month during which you enroll in Part B.

EMERGENCY CARE

Care given for a medical emergency when you believe that your health is in serious danger when every second counts.

EMERGENCY ROOM (HOSPITAL)

A portion of the hospital where emergency diagnosis and treatment of illness or injury is provided.

EMPLOYEE

For purposes of the Medicare Secondary Payer (MSP) provisions, an employee is an individual who works for an employer, whether on a full- or part-time basis, and receives payment for his/her work.

EMPLOYER

Individuals and organizations engaged in a trade or business, plus entities exempt from income tax such as religious, charitable, and educational institutions, the governments of the United States, Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, and the District of Columbia, and the agencies, instrumentalities, and political subdivisions of these governments.

EMPLOYER BULLETIN BOARD SERVICE

An electronic bulletin board service offered by the COB Contractor. Employers that have to report on less than 500 workers can fulfill their requirements under the Internal Revenue Service/Social Security Administration/Health Care Financing Administration (IRS/SSA/HCFA) Data Match law by downloading a questionnaire entry application from the bulletin board. The information will be processed through several logic and consistency edits. Once the employer has completed the information, he or she will return the completed file through the bulletin board.

EMPLOYER GROUP HEALTH PLAN (GHP)

A GHP is a health plan that:

  • Gives health coverage to employees, former employees, and their families, and
  • Is from an employer or employee organization.
EMPLOYER IDENTIFIER

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

EMTALA (EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT)

The Emergency Medical Treatment and Active Labor Act, codified at 42 U.S.C. 1395dd. EMTALA requires any Medicare-participating hospital that operates a hospital emergency department to provide an appropriate medical screening examination to any patient that requests such an examination. If the hospital determines that the patient has an emergency medical condition, it must either stabilize the patient's condition or arrange for a transfer; however, the hospital may only transfer the patient if the medical benefits of the transfer outweigh the risks or if the patient requests the transfer. CMS regulations at 42 C.F.R. 489.24(b) and 413.65(g) further clarify the statutory language.

EMT-BASIC

The EMT-Basic has the knowledge and skills of the First Responder but is also qualified to function as minimum staff for an ambulance. Example: At the scene of a cardiac arrest, the EMT-Basic would be expected to defibrillate and ventilate the patient with a manually operated device and supplemental oxygen.

EMT-INTERMEDIATE

The EMT-Intermediate has the knowledge and skills of the First Responder and EMT-Basic, but in addition can perform essential advanced techniques and administer a limited number of medications. Example: At the scene of a cardiac arrest, the EMT-Intermediate would be expected to intubate and administer first line Advanced Cardiac Life Support (ACLS) medications.

EMT-PARAMEDIC

The EMT-Paramedic has demonstrated the compentencies expected of a Level 3 (EMT-Intermediate) provider, but can administer additional interventions and medications. Example: At the scene of a cardiac arrest, the EMT-Paramedic might administer second line Advanced Cardiac Life Support (ACLS) medications and use an external pacemaker.

ENCOUNTER DATA

Detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form. Encounter data are also sometimes referred to as "shadow claims".

END STAGE RENAL DISEASE TREATMENT FACILITY

A facility, other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.

END-STAGE RENAL DISEASE

Permanent kidney failure. That stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life.

END-STAGE RENAL DISEASE (ESRD)

Permanent kidney failure requiring dialysis or a kidney transplant.

END-STAGE RENAL DISEASE NETWORK

A group of private organizations that make sure you are getting the best possible care. ESRD networks also keep your facility aware of important issues about kidney dialysis and transplants.

ENHANCED BENEFITS

Defined as Additional, Mandatory and Optional Supplemental benefits.

ENROLL

To join a health plan.

ENROLLEE HOTLINES

Toll-free telephone lines, usually staffed by the State or enrollment broker that beneficiaries may call when they encounter a problem with their MCO/PHP. The people who staff hotlines are knowledgeable about program policies and may play an "intake and triage" role or may assist in resolving the problem.

ENROLLMENT

Is the process by which a Medicaid eligible person becomes a member of a managed care plan. Enrollment data refer to the managed care plan's information on Medicaid eligible individuals who are plan members. The managed care plan gets its enrollment data from the Medicaid program's eligibility system.

ENROLLMENT FEE

The amount you must pay every year to get a Medicare-approved drug discount card.

ENROLLMENT PERIOD

A certain period of time when you can join a Medicare health plan if it is open and accepting new Medicare members. If a health plan chooses to be open, it must allow all eligible people with Medicare to join.

ENROLLMENT/PART A

There are four periods during which you can enroll in premium Part A: Initial Enrollment Period (IEP), General Enrollment Period (GEP), Special Enrollment Period (SEP), and Transfer Enrollment Period (TEP).

  • Initial Enrollment Period: The IEP is the first chance you have to enroll in premium Part A. Your IEP starts 3 months before you first meet all the eligibility requirements for Medicare and continues for 7 months.
  • General Enrollment Period: January 1 through March 31 of each year. Your premium Part A coverage is effective July 1 after the GEP in which you enroll.
  • Special Enrollment Period: The SEP is for people who did not take premium Part A during their IEP because you or your spouse currently work and have group health plan coverage through your current employer or union. You can sign up for premium Part A at any time you are covered under the Group Health Plan based on current employment. If the employment or group health coverage ends, you have 8 months to sign up. The 8 months start the month after the employment ends or the group health coverage ends, whichever comes first.
  • Transfer Enrollment Period: The TEP is for people age 65 or older who have Part B only and are enrolled in a Medicare managed care plan. You can sign up for premium Part A during any month in which you are enrolled in a Medicare managed care plan. If you leave the plan or if the plan coverage ends, you have 8 months to sign up. The 8 months start the month after the month you leave the plan or the plan coverage ends. If you enroll in Part B or Part A (if you don't get it automatically without paying a premium) during the GEP, your coverage starts on July 1. (See Enrollment.)
ENTITY ASSETS

Assets which the reporting entity has authority to use in its operations (i.e., management has the authority to decide how funds are used, or management is legally obligated to use funds to meet entity obligations).

EPISODE

60 day unit of payment for HH PPS.

EPISODE OF CARE

The health care services given during a certain period of time, usually during a hospital stay.

EQRO ORGANIZATION

Federal law and regulations require States to use an External Quality Review Organization (EQRO) to review the care provided by capitated managed care entities. EQROs may be Peer Review Organizations (PROs), another entity that meets PRO requirements, or a private accreditation body.

EQUIVALENCY REVIEW

The process CMS employs to compare an accreditation organization's standards, processes and enforcement activities to the comparable CMS requirements, processes and enforcement activities.

ESRD ELIGIBILITY REQUIREMENTS

To qualify for Medicare under the renal provision, a person must have ESRD and either be entitled to a monthly insurance benefit under Title II of the Act (or an annuity under the Railroad Retirement Act), be fully or currently insured under Social Security (railroad work may count), or be the spouse or dependent child of a person who meets at least one of the two last requirements. There is no minimum age for eligibility under the renal disease provision. An Application for Health Insurance Benefits Under Medicare for Individuals with Chronic Renal Disease, Form HCFA-43 (effective October 1, 1978) must be filed.

ESRD FACILITY

A facility, which is approved to furnish at least one specific, ESRD service. These services may be performed in a renal transplantation center, a renal dialysis facility, self-dialysis unit, or special purpose renal dialysis facility.

ESRD NETWORK

All Medicare approved ESRD facilities in a designated geographic area specified by CMS.

ESRD NETWORK ORGANIZATION

The administrative governing body of the ESRD Network and liaison to the Federal Government.

ESRD PATIENT

A person with irreversible and permanent kidney failure who requires a regular course of dialysis or kidney transplantation to maintain life.

ESRD SERVICES

The type of care or service furnished to an ESRD patient. Such types of care are transplantation; dialysis; outpatient dialysis; staff assisted dialysis; home dialysis; and self-dialysis and home dialysis training.

EVIDENCE

Signs that something is true or not true. Doctors can use published studies as evidence that a treatment works or does not work.

EVIDENCE OF FUNDING

Proof that sufficient funds are available for completion of the project. Usually a copy of the face sheet of the grant, contract, or cooperative agreement is sufficient.

EXCESS CHARGES

If you are in the Original Medicare Plan, this is the difference between a doctor?s or other health care provider?s actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.

EXCLUSIONS (MEDICARE)

Items or services that Medicare does not cover, such as most prescription drugs, long-term care, and custodial care in a nursing or private home.

EXPEDITED APPEAL

A Medicare+Choice organization's second look at whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.

EXPEDITED ORGANIZATION DETERMINATION

A fast decision from the Medicare+Choice organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.

EXPENDITURE

The issuance of checks, disbursement of cash, or electronic transfer of funds made to liquidate an expense regardless of the fiscal year the service was provided or the expense was incurred. When used in the discussion of the Medicaid program, expenditures refer to funds spent as reported by the States. The same as an Outlay.

EXPENSE

Funds actually spent or incurred providing goods, rendering services, or carrying out other mission related activities during a period. Expenses are computed using accrual accounting techniques which recognize costs when incurred and revenues when earned and include the effect of accounts receivables and accounts payable on determining annual income.

EXTENDED CARE SERVICES

In the context of this report, an alternate name for "skilled nursing facility services."

EXTERNAL QUALITY REVIEW ORGANIZATION

Is the organization with which the State contracts to evaluate the care provided to Medicaid managed eligibles. Typically the EQRO is a peer review organization. It may conduct focused medical record reviews (i.e. Reviews targeted at a particular clinical condition) or broader analyses on quality. While most EQRO contractors rely on medical records as the primary source of information, they may also use eligibility data and claims/encounter data to conduct specific analyses.


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Term Definition
FACILITY CHARGE

Some plans may vary cost shares for services based on place of treatment; in effect, charging a cost for the facility in which the service is received.

FALSE NEGATIVES

Occur when the medical record contains evidence of a service that does not exist in the encounter data. This is the most common problem in partially or fully capitated plans because the provider does not need to submit an encounter in order to receive payment for the service, and therefore may have a weaker incentive to conform to data collection standards.

FALSE POSITIVES

Occurs when the encounter data contain evidence of a service that is not documented in the patient's medical record. If we assume that the medical record contains complete information on the patients medical history, a false positive may be considered a fraudulent service. In a fully capitated environment, however, the provider would receive no additional reimbursement for the submission of a false positive encounter.

FEDERAL GENERAL REVENUES

Federal tax revenues (principally individual and business income taxes) not earmarked for a particular use.

FEDERAL INSURANCE CONTRIBUTION ACT PAYROLL TAX

Medicare's share of FICA is used to fund the HI Trust Fund. In FY 1995, employers and employees each contributed 1.45 percent of taxable wages, with no limitations, to the HI Trust Fund.

FEDERAL INSURANCE CONTRIBUTIONS ACT

Provision authorizing taxes on the wages of employed persons to provide for the OASDI and HI programs. Covered workers and their employers pay the tax in equal amounts.

FEDERAL MANAGERS' FINANCIAL INTEGRITY ACT

A program to identify management inefficiencies and areas vulnerable to fraud and abuse and to correct such weaknesses with improved internal controls.

FEDERAL MEDICAL ASSISTANCE PERCENTAGE

The portion of the Medicaid program, which is paid by the Federal government.

FEDERAL REGISTER

The "Federal Register" s the official daily publication for rules, proposed rules and notices of federal agencies and organizations, as well as Executive Orders and other Presidential documents.

FEDERALLY QUALIFIED HEALTH CENTER

A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general supervision of a physician.

FEDERALLY QUALIFIED HEALTH CENTER (FQHC)

Health centers that have been approved by the government for a program to give low cost health care. Medicare pays for some health services in FQHCs that are not usually covered, like preventive care. FQHCs include community health centers, tribal health clinics, migrant health services, and health centers for the homeless.

FEE SCHEDULE

A complete listing of fees used by health plans to pay doctors or other providers.

FEE-FOR-SERVICES

A plan or PCCM is paid for providing services to enrollees solely through fee-for-service payments plus in most cases, a case management fee.

FEE-SCREEN YEAR

A specified period of time in which SMI-recognized fees pertain. The fee-screen year period has changed over the history of the program.

FINANCIAL DATA

Data regarding the financial the status of managed care entities (e.g. the medical loss ratio).

FINANCIAL INTERCHANGE

Provisions of the Railroad Retirement Act providing for transfers between the trust funds and the Social Security Equivalent Benefit Account of the Railroad Retirement program in order to place each trust fund in the same position as if railroad employment had always been covered under Social Security.

FIRST RESPONDER

The First Responder uses a limited amount of equipment to perform initial assessment and intervention and is trained to assist other Emergency Medical Services (EMS)providers. Example: At the scene of a cardiac arrest, the First Responder would be expected to notify EMS (if not already notified) and initiate CPR with an oral airway and a barrier device.

FIRST RESPONDER

The First Responder uses a limited amount of equipment to perform initial assessment and intervention and is trained to assist other Emergency Medical Services (EMS)providers. Example: At the scene of a cardiac arrest, the First Responder would be expected to notify EMS (if not already notified) and initiate CPR with an oral airway and a barrier device.

FISCAL INTERMEDIARY

A private company that has a contract with Medicare to pay Part A and some Part B bills. (Also called "Intermediary.")

FISCAL YEAR

For Medicare, a year-long period that runs from October 1st through September 30th of the next year. The government and some insurance companies follow a budget that is planned for a fiscal year.

FIXED CAPITAL ASSETS

The net worth of facilities and other resources.

FLAT FILE

This term usually refers to a file that consists of a series of fixed-length records that include some sort of record type code.

FOCUSED STUDIES

State required studies that examine a specific aspect of health care (such as prenatal care) for a defined point in time. These projects are usually based on information extracted from medical records or MCO/PHP administrative data such as enrollment files and encounter /claims data. State staff, EQRO staff, MCO/PHP staff or more than one of these entities may perform such studies at the discretion of the State.

FORMAT

Under HIPAA, this is those data elements that provide or control the enveloping or hierarchical structure, or assist in identifying data content of, a transaction.

FORMULARY

A list of certain drugs and their proper dosages. In some Medicare health plans, doctors must order or use only drugs listed on the health plan's formulary.

FORMULARY DRUGS

Listing of prescription medications which are approved for use and/or coverage by the plan and which will be dispensed through participating pharmacies to covered enrollees.

FRAUD

The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s).

FRAUD AND ABUSE

Fraud: To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse: Payment for items or services that are billed by mistake by providers, but should not be paid for by Medicare. This is not the same as fraud.

FREE LOOK (MEDIGAP POLICY)*

A period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled. If you cancel, you will get your money back.

FREEDOM OF INFORMATION ACT

A provision that any person has a right, enforceable in court, of access of federal agency records, except to the extent that such records, or portions thereof, are protected from disclosure by one of nine exemptions or by one of three special law enforcement record exclusions.

FREEDOM OF INFORMATION ACT (FOIA)

A law that requires the U.S. Government to give out certain information to the public when it receives a written request. FOIA applies only to records of the Executive Branch of the Federal Government, not to those of the Congress or Federal courts, and does not apply to state governments, local governments, or private groups.

FREQUENCY DISTRIBUTION

An exhaustive list of possible outcomes for a variable, and the associated probability of each outcome. The sum of the probabilities of all possible outcomes from a frequency distribution is 100 percent.

FULL CAPITATION

The plan or Primary Care Case Manager is paid for providing services to enrollees through a combination of capitation and fee for service reimbursements.

FULL CAPITATION (FUL)

A plan is paid for providing services to enrollees solely through capitation.

FULL PSC OR FULL PROGRAM SAFEGUARD CONTRACTOR

For the purposes of this umbrella SOW, a full PSC is one that performs all of the fundamental activities contained in Section 3, General Requirements, under a Task Order.

FULLY ACCREDITED

Designation that all the elements within all the accreditation standards for which the accreditation organization has been approved by CMS have been surveyed and fully met or have otherwise been determined to be acceptable without significant adverse findings, recommendations, required actions or corrective actions.


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Term Definition
GAPFILLING

Used when no comparable, existing test is available. Carrier specific amounts are used to establish a national limitation amount for the following year.

GAPS

The costs or services that are not covered under the Original Medicare Plan.

GATEKEEPER

In a managed care plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.

GENERAL ENROLLMENT PERIOD (GEP)

The General Enrollment Period is January 1 through March 31 of each year. If you enroll in Premium Part A or Part B during the General Enrollment Period, your coverage starts on July 1.

GENERAL FUND OF THE TREASURY

Funds held by the Treasury of the United States, other than revenue collected for a specific trust fund (such as SMI) and maintained in a separate account for that purpose. The majority of this fund is derived from individual and business income taxes.

GENERAL REVENUE

Income to the SMI trust fund from the general fund of the Treasury. Only a very small percentage of total SMI trust fund income each year is attributable to general revenue.

GENERIC DRUG

A prescription drug that has the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

GOVERNMENTAL ASSETS, LIABILITIES

Assets or liabilities that arise from transactions between a federal entity and a nonfederal entity.

GRAMM-RUDMAN-HOLLINGS ACT

The Balanced Budget and Emergency Deficit Control Act of 1985.

GRIEVANCE

A complaint about the way your Medicare health plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you are unhappy with the way a staff person at the plan has behaved toward you. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered (see Appeal).

GRIEVANCES AND COMPLAINTS

Information about grievances and complaints submitted to the health plan.

GROSS DOMESTIC PRODUCT

The total dollar value of all goods and services produced in a year in the United States, regardless of who supplies the labor or property.

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.

GROUP OR NETWORK HMO

A health plan that contracts with group practices of doctors to give services in one or more places.

GUARANTEED ISSUE RIGHTS (ALSO CALLED "MEDIGAP PROTECTIONS")

Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can't deny you insurance coverage or place conditions on a policy, must cover you for all pre-existing conditions, and can't charge you more for a policy because of past or present health problems.

GUARANTEED RENEWABLE

A right you have that requires your insurance company to automatically renew or continue your Medigap policy, unless you make untrue statements to the insurance company, commit fraud or don?t pay your premiums.

GUIDELINES

Guidelines are systematically developed by appropriate groups to assist practitioners and patient decisions about appropriate health care for specific clinical circumstances.


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Term Definition
HCFA-1450

HCFA's name for the institutional uniform claim form, or UB-92.

HCFA-1500

HCFA's name for the professional uniform claim form. Also known as the UCF-1500.

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 CARE CODE MAINTENANCE COMMITTEE

An organization administered by the BCBSA that is responsible for maintaining certain coding schemes used in the X12 transactions and elsewhere. These include the Claim Adjustment Reason Codes, the Claim Status Category Codes, and the Claim Status Codes.

HEALTH CARE PREPAYMENT PLAN

A type of managed care organization. In return for a monthly premium, plus any applicable deductible or co-payment, all or most of an individual's physician services will be provided by the HCPP. The HCPP will pay for all services it has arranged for (and any emergency services) whether provided by its own physicians or its contracted network of physicians. If a member enrolled in an HCPP chooses to receive services that have not been arranged for by the HCPP, he/she is liable for any applicable Medicare deductible and/or coinsurance amounts, and any balance would be paid by the regional Medicare carrier.

HEALTH CARE PROVIDER

A person who is trained and licensed to give health care. Also, a place that is licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.

HEALTH CARE PROVIDER TAXONOMY COMMITTEE

An organization administered by the NUCC that is responsible for maintaining the Provider Taxonomy coding scheme used in the X12 transactions. The detailed code maintenance is done in coordination with X12N/TG2/WG15.

HEALTH CARE QUALITY IMPROVEMENT PROGRAM

HCQIP is a program, which supports the mission of CMS to assure health care security for beneficiaries. The mission of HCQIP is to promote the quality, effectiveness, and efficiency of services to Medicare beneficiaries by strengthening the community of those committed to improving quality, monitoring and improving quality of care, communicating with beneficiaries and health care providers, practitioners, and plans to promote informed health choices, protecting beneficiaries from poor care, and strengthening the infrastructure.

HEALTH EMPLOYER DATA AND INFORMATION SET (HEDIS)

A set of standard performance measures that can give you information about the quality of a health plan. You can find out about the quality of care, access, cost, and other measures to compare managed care plans. The Centers for Medicare & Medicaid Services (CMS) collects HEDIS data for Medicare plans. (See Centers for Medicare & Medicaid Services.)

HEALTH INFORMATICS STANDARDS BOARD

An ANSI-accredited standards group that has developed an inventory of candidate standards for consideration as possible HIPAA standards.

HEALTH INSURANCE ASSOCIATION OF AMERICA

An industry association that represents the interests of commercial health care insurers. The HIAA participates in the maintenance of some code sets, including the HCPCS Level II codes.

HEALTH INSURANCE CLAIMS NUMBER

The number assigned by the Social Security Administration to an individual identifying him/her as a Medicare beneficiary. This number is shown on the beneficiary's insurance card and is used in processing Medicare claims for that beneficiary.

HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA)

A law passed in 1996 which is also sometimes called the "Kassebaum-Kennedy" law. This law expands your health care coverage if you have lost your job, or if you move from one job to another, HIPAA protects you and your family if you have: pre-existing medical conditions, and/or problems getting health coverage, and you think it is based on past or present health. HIPAA also:

  • limits how companies can use your pre-existing medical conditions to keep you from getting health insurance coverage;
  • usually gives you credit for health coverage you have had in the past;
  • may give you special help with group health coverage when you lose coverage or have a new dependent; and
  • generally, guarantees your right to renew your health coverage. HIPAA does not replace the states' roles as primary regulators of insurance.
HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996

A regulation to guarantee patients new rights and protections against the misuse or disclosure of their health records.

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 INSURING ORGANIZATION

An entity that provides for or arranges for the provision of care and contracts on a prepaid capitated risk basis to provide a comprehensive set of services.

HEALTH LEVEL SEVEN

An ANSI-accredited group that defines standards for the cross-platform exchange of information within a health care organization. HL7 is responsible for specifying the Level Seven OSI standards for the health industry. The X12 275 transaction will probably incorporate the HL7 CRU message to transmit claim attachments as part of a future HIPAA claim attachments standard. The HL7 Attachment SIG is responsible for the HL7 portion of this standard.

HEALTH MAINTENANCE ORGANIZATIONS (HMO)

A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You usually must get your care from the providers in the plan.

HEALTH MAINTENANCE ORGANIZATIONS (HMO)

A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You usually must get your care from the providers in the plan.

HEALTH PLAN

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

HEALTHCARE COMMON PROCEDURAL CODING SYSTEM

A medical code set that identifies health care procedures, equipment, and supplies for claim submission purposes. It has been selected for use in the HIPAA transactions. HCPCS Level I contains numeric CPT codes which are maintained by the AMA. HCPCS Level II contains alphanumeric codes used to identify various items and services that are not included in the CPT medical code set. These are maintained by HCFA, the BCBSA, and the HIAA. HCPCS Level III contains alphanumeric codes that are assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These are usually called "local codes", and must have "W", "X", "Y", or "Z" in the first position. HCPCS Procedure Modifier Codes can be used with all three levels, with the WA - ZY range used for locally assigned procedure modifiers.

HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION

An organization for the improvement of the financial management of healthcare-related organizations. The HFMA sponsors some HIPAA educational seminars.

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.)

HEARING

A procedure that gives a dissatisfied claimant an opportunity to present reasons for the dissatisfaction and to receive a new determination based on the record developed at the hearing. Hearings are provided for in 1842(b)(3)(C) of the Act.

HEDIS MEASURES FROM ENCOUNTER DATA

Measures from encounter data as opposed to having the plans generate HEDIS measures. HEDIS is a collection of performance measures and their definitions produced by the National Committee for Quality Assurance (NCQA).

HEMATOCRIT

A measure of red blood cell volume in the blood.

HEMODIAFILTRATION

Simultaneous hemodialysis and hemofiltration which involves the removal of large volumes of fluid and fluid replacement to maintain hemodynamic stability. It requires the use of ultra pure dialysate or intravenous fluid for volume replacement. Also called high flux hemodiafiltration and double high flux hemodiafiltration.

HEMODIALYSIS

A method of dialysis in which blood from a patient's body is circulated through an external device or machine and then returned to the patient's bloodstream. Such an artificial kidney machine is usually designed to remove fluids and metabolic end products from the bloodstream by placing the blood in contact with a semi-permeable membrane, which is bathed on one side by an appropriate chemical solution, referred to as dialysate.

HEMODIALYSIS (HD)

This treatment is usually done in a dialysis facility but can be done at home with the proper training and supplies. HD uses a special filter (called a dialyzer or artifical kidney) to clean your blood. The filter connects to a machine. During treatment, your blood flows through tubes into the filter to clean out wastes and extra fluids. Then the newly cleaned blood flows through another set of tubes and back into your body (See dialysis and peritoneal dialysis.).

HEMOFILTRATION

Fluid removal.

HIGH COST ALTERNATIVE

See "Assumptions."

HIGH RISK AREA

A potential flaw in management controls requiring management attention and possible corrective action.

HIPAA DATA DICTIONARY OR HIPAA DD

A data dictionary that defines and cross-references the contents of all X12 transactions included in the HIPAA mandate. It is maintained by X12N/TG3.

HOME

Location, other than a hospital or other facility, where the patient receives care in a private residence.

HOME AND COMMUNITY-BASED SERVICE WAIVER PROGRAMS (HCBS)

The HCBS programs offer different choices to some people with Medicaid. If you qualify, you will get care in your home and community so you can stay independent and close to your family and friends. HCBS programs help the elderly and disabled, mentally retarded, developmentally disabled, and certain other disabled adults. These programs give quality and low-cost services.

HOME HEALTH AGENCY

An organization that gives home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides.

HOME HEALTH CARE

Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

HOME PATIENTS

Medically-able individuals, who have their own dialysis equipment at home and after proper training, perform their own dialysis treatment alone or with the assistance of a helper.

HOMEBOUND

Normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious service. A need for adult day care doesn't keep you from getting home health care.

HOSPICE

Hospice is a special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is covered under Medicare Part A (Hospital Insurance).

HOSPICE CARE

A special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is covered under Medicare Part A (Hospital Insurance).

HOSPITAL ASSUMPTIONS

These include differentials between hospital labor and non-labor indices compared with general economy labor and non-labor indices; rates of admission incidence; the trend toward treating less complicated cases in outpatient settings; and continued improvement in DRG coding.

HOSPITAL COINSURANCE

For the 61st through 90th day of hospitalization in a benefit period, a daily amount for which the beneficiary is responsible, equal to one-fourth of the inpatient hospital deductible; for lifetime reserve days, a daily amount for which the beneficiary is responsible, equal to one-half of the inpatient hospital deductible (see "Lifetime reserve days").

HOSPITAL INDEMNITY INSURANCE

This kind of insurance pays a certain cash amount for each day you are in the hospital up to a certain number of days. Indemnity insurance doesn?t fill gaps in your Medicare coverage.

HOSPITAL INPUT PRICE INDEX

An alternate name for "hospital market basket."

HOSPITAL INSURANCE

The Medicare program that covers specified inpatient hospital services, posthospital skilled nursing care, home health services, and hospice care for aged and disabled individuals who meet the eligibility requirements. Also known as Medicare Part A.

HOSPITAL INSURANCE (PART A)

The part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.

HOSPITAL MARKET BASKET

The cost of the mix of goods and services (including personnel costs but excluding nonoperating costs) comprising routine, ancillary, and special care unit inpatient hospital services.

HOSPITALIST

A doctor who primarily takes care of patients when they are in the hospital. This doctor will take over your care from your primary doctor when you are in the hospital, keep your primary doctor informed about your progress, and will return you to the care of your primary doctor when you leave the hospital.

HYBRID ENTITY

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

HYDRATION

This is the level of fluid in the body. The loss of fluid, or dehydration, occurs when you lose more water or fluid than you take in. Your body cannot keep adequate blood pressure, get enough oxygen and nutrients to the cells, or get rid of wastes if it has too little fluid.


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Term Definition
ICD & ICD-N-CM & ICD-N-PCS

International Classification of Diseases, with "n" = "9" for Revision 9 or "10" for Revision 10, with "CM" = "Clinical Modification", and with "PCS" = "Procedure Coding System".

IMMUNOSUPPRESSIVE DRUGS

Transplant drugs used to reduce the risk of rejecting the new kidney after transplant. Transplant patients will need to take these drugs for the rest of their lives.

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.

IMPLEMENTATION SPECIFICATION

Under HIPAA, this is the specific instructions for implementing a standard.

IMPROVEMENT PLAN

A plan for measurable process or outcome improvement. The plan is usually developed cooperatively by a provider and the Network. The plan must address how and when its results will be measured.

INAPPROPRIATE UTILIZATION

Utilization of services that are in excess of a beneficiary's medical needs and condition (overutilization) or receiving a capitated Medicare payment and failing to provide services to meet a beneficiary's medical needs and condition (underutilization).

INCIDENCE

The frequency of new occurrences of a condition within a defined time interval. The incidence rate is the number of new cases of specific disease divided by the number of people in a population over a specified period of time, usually one year.

INCOME RATE

The ratio of income from tax revenues on an incurred basis (payroll tax contributions and income from the taxation of OASDI benefits) to the HI taxable payroll for the year.

INCURRED BASIS

The costs based on when the service was performed rather than when the payment was made.

INDEPENDENT LABORATORY

A freestanding clinical laboratory meeting conditions for participation in the Medicare program and billing through a carrier. A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.

INDICATOR

A key clinical value or quality characteristic used to measure, over time, the performance, processes, and outcomes of an organization or some component of health care delivery.

INFORMATION MODEL

A conceptual model of the information needed to support a business function or process.

INFORMATION, COUNSELING, AND ASSISTANCE PROGRAM

(See State Health Insurance Assistance Program.)

INFUSION PUMPS

Pumps for giving fluid or medication into your vein at a specific rate or over a set amount of time.

INITIAL (CLAIM) DETERMINATION

The first adjudication made by a carrier or fiscal intermediary (FI) (i.e., the affiliated contractor) following a request for Medicare payment or the first determination made by a PRO either in a prepayment or postpayment context.

INITIAL COVERAGE ELECTION PERIOD

The 3 months immediately before you are entitled to Medicare Part A and enrolled in Part B. You may choose a Medicare health plan during your Initial Coverage Election Period. The plan must accept you unless it has reached its limit in the number of members. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP). (See Election Periods; Enrollment/Part A; Initial Enrollment Period (IEP).)

INITIAL ENROLLMENT PERIOD

The Initial Enrollment Period is the first chance you have to enroll in Medicare Part B. Your Initial Enrollment Period starts three months before you first meet all the eligibility requirements for Medicare and lasts for seven months.

INITIAL ENROLLMENT QUESTIONNAIRE (IEQ)

A questionnaire sent to you when you become eligible for Medicare to find out if you have other insurance that should pay your medical bills before Medicare.

INPATIENT CARE

Health care that you get when you are admitted to a hospital.

INPATIENT HOSPITAL

A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services by or under the supervision of physicians, to patients admitted for a variety of medical conditions.

INPATIENT HOSPITAL DEDUCTIBLE

An amount of money that is deducted from the amount payable by Medicare Part A for inpatient hospital services furnished to a beneficiary during a spell of illness.

INPATIENT HOSPITAL SERVICES

These services include bed and board, nursing services, diagnostic or therapeutic services, and medical or surgical services.

INPATIENT PSYCHIATRIC FACILITY

A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

INSOLVENCY

When a health plan has no money or other means to stay open and give health care to patients.

INSURER

An insurer of a GHP is an entity that, in exchange for payment of a premium, agrees to pay for GHP-covered services received by eligible individuals.

INTER OR INTRA AGENCY AGREEMENT

A written contract in which the Federal agency agrees to provide to, purchase from, or exchange with another Federal agency, services (including data), supplies or equipment. Inter-agency agreements are between at least one component with DHHS and another Federal agency or component thereof. Intra-agency agreements are between two or more agencies within DHHS.

INTEREST

A payment for the use of money during a specified period.

INTERFUND BORROWING

The borrowing of assets by a trust fund (OASI, DI, HI, or SMI) from another of the trust funds when one of the funds is in danger of exhaustion. Interfund borrowing was authorized only during 1982-1987.

INTERMEDIARY

A private company that has a contract with Medicare to pay Part A and some Part B bills.

INTERMEDIARY HEARING

That hearing provided for in 42 CFR 405.1809.

INTERMEDIARY/PROGRAM SAFEGUARD CONTRACTOR DETERMINATION

A determination as defined in 42 CFR 405.1801 under the definition for Intermediary Determination.

INTERMEDIATE ASSUMPTIONS

See "Assumptions."

INTERMEDIATE CARE FACILITY/MENTALLY RETARDED

A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care available in a hospital or skilled nursing facility.

INTERMEDIATE ENTITIES

These are entities, which contract between an MCO or one of its subcontractors and a physician or physician group, other than physician groups themselves. An IPA is considered to be an intermediate entity if it contracts with one or more physician groups in addition to contracting with individual physicians.

INTERMITTENT PERITONEAL DIALYSIS

An intermittent (periodic), supine regimen, which uses intermittent flow technique, automated assisted manual, or manual method in dialysis sessions two to four times weekly.

INTERNAL CONTROLS

Management systems and policies for reasonably documenting, monitoring, and correcting operational processes to prevent and detect waste and to ensure proper payment.

INTERNAL REVENUE SERVICE/SOCIAL SECURITY ADMINISTRATION/HEALTH CARE FINANCING ADMINISTRATION DATA MATCH

A process by which information on employers and employees is provided by the IRS and SSA and is analyzed by CMS for use in contacting employers concerning possible periods of MSP. This information is used to update the CWF-Medicare Common Working File.

INTERNATIONAL CLASSIFICATION OF DISEASES

A medical code set maintained by the World Health Organization (WHO). The primary purpose of this code set was to classify causes of death. A US extension, maintained by the NCHS within the CDC, identifies morbidity factors, or diagnoses. The ICD-9-CM codes have been selected for use in the HIPAA transactions.

INTERNATIONAL ORGANIZATION FOR STANDARDIZATION

An organization that coordinates the development and adoption of numerous international standards. "ISO" is not an acronym, but the Greek word for "equal".

INTERNIST

A doctor who finds and treats health problems in adults.

INTRAGOVERNMENTAL ASSETS, LIABILITIES

Assets or liabilities that arise from transactions among federal entities.


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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.

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

An organization that accredits healthcare organizations. In the future, the JCAHO may play a role in certifying these organizations' compliance with the HIPAA A/S requirements.


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Term Definition
LARGE GROUP HEALTH PLAN

A group health plan that covers employees of either an employer or employee organization that has 100 or more employees.

LETTER OF REQUEST

A formal request from the requestor on organizational letterhead detailing their data needs and purposes. Additionally, if this project is federally funded a letter of Support is required from the federal Project Officer on their organizational letterhead.

LETTER OF SUPPORT

A letter from the Federal Project Officer justifying the need for CMS data and supporting the requestor's use of such data.

LIABILITY DETERMINATION

Determination based on 1879 or 1870 or 1842(L) of the Act, of whether the beneficiary and the provider did not and could not have been reasonably expected to know that payment would not be made for services.

LIABILITY INSURANCE

Liability insurance is insurance that protects against claims for negligence or inappropriate action or inaction, which results in injury to someone or damage to property.

LICENSED (LICENSURE)

This means a long-term care facility has met certain standards set by a State or local government agency.

LICENSED BY THE STATE AS A RISK-BEARING ENTITY

An entity that is licensed or otherwise authorized by the State to assume risk for offering health insurance or health benefits coverage. The entity is authorized to accept prepaid capitation for providing, arranging, or paying for comprehensive health services under an M+C contract. Designation that an M+C organization has been reviewed and determined "fully accredited" by a CMS-approved accrediting organization for those standards within the deeming categories that the accrediting organization has the authority to deem.

LIFETIME RESERVE DAYS

In the Original Medicare Plan, 60 days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. These 60 reserve days can be used only once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($438 in 2004).

LIFETIME RESERVE DAYS (MEDICARE)

Sixty days that Medicare will pay for when you are in a hospital for more than 90 days. These 60 reserve days can be used only once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($406 in 2002).

LIMITING CHARGE

In the Original Medicare Plan, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don?t accept assignment. The limiting charge is 15% over Medicare?s approved amount. The limiting charge only applies to certain services and doesn?t apply to supplies or equipment.

LINE ITEM

Service or item specific detail of claim.

LIVING DONOR KIDNEY TRANSPLANT

The surgical procedure of excising a kidney from a living donor and implanting it into a suitable recipient.

LIVING WILLS

A legal document also known as a medical directive or advance directive. It states your wishes regarding life-support or other medical treatment in certain circumstances, usually when death is imminent.

LOCAL CODE(S)

A generic term for code values that are defined for a state or other political subdivision, or for a specific payer. This term is most commonly used to describe HCPCS Level III Codes, but also applies to state-assigned Institutional Revenue Codes, Condition Codes, Occurrence Codes, Value Codes, etc.

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.

LOCAL COVERAGE DETERMINATION (LCD)

An LCD, as established by Section 522 of the Benefits Improvement and Protection Act, is a decision by a Medicare Contractor (A/B MAC, DME MAC, HHH MAC, Fiscal Intermediary or Carrier) whether to cover a particular service or item on an contractor-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary). The difference between LMRPs and LCDs is that LCDs consist only of "reasonable and necessary" information, while LMRPs frequently also contained benefit category or statutory provisions.

For a full description of the process and criteria used in developing LCDs, refer to Chapter 13 of the Medicare Program Integrity Manual.

LOCAL MEDICAL REVIEW POLICY (LMRP)

LMRP was an administrative and educational tool to assist providers, physicians and suppliers in submitting correct claims for payment. They outlined how contractors were to review claims to ensure that they met Medicare coverage requirements.

LMRPs pre-date LCDs; and, were retired in their entirety by December 2005. All LMRP document versions are posted on the MCD Archive. LMRPs could include "reasonable and necessary" information, as well as benefit category and statutory exclusion provisions. LCDs and Articles replaced LMRPs.

LOGICAL OBSERVATION IDENTIFIERS, NAMES AND CODES

A set of universal names and ID codes that identify laboratory and clinical observations. These codes, which are maintained by the Regenstrief Institute, are expected to be used in the HIPAA claim attachments standard.

LONG RANGE

The next 75 years.

LONGER TERM CARE MINIMUM DATA SET

Is the core set of screening and assessment elements of the Resident Assessment Instrument (RAI). This assessment system provides a comprehensive, accurate, standardized, reproducible assessment of each long term care facility resident's functional capabilities and helps staff to identify health problems. This assessment is performed on every resident in a Medicare and/or Medicaid-certified long term care facility including private pay.

LONG-TERM CARE

A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn?t pay for this type of care if this is the only kind of care you need.

LONG-TERM CARE INSURANCE

A private insurance policy to help pay for some long-term medical and non-medical care, like help with activities of daily living. Because Medicare generally does not pay for long-term care, this type of insurance policy may help provide coverage for long-term care that you may need in the future. Some long-term care insurance policies offer tax benefits; these are called "Tax-Qualified Policies."

LONG-TERM CARE OMBUDSMAN

An advocate (supporter) for nursing home and assisted living facility residents who works to resolve problems between residents and nursing homes or assisted living facilities.

LOOP

A repeating structure or process.

LOW COST ALTERNATIVE

See "Assumptions."


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Term Definition
M+C ORGANIZATION (MEDICARE+CHOICE)

A public or private entity organized and licensed by a State as a risk-bearing entity (with the exception of provider sponsored organization receiving waivers) that is certified by CMS as meeting the M+C contract requirements. See 42 C.F.R. 422.2.

M+C PLAN

Health benefits coverage offered under a policy or contract offered by a Medicare+Choice Organization under which a specific set of health benefits are offered at a uniform premium and uniform level of cost-sharing to all Medicare beneficiaries residing in the service area of the M+C plan. See 42 C.F.R. 422.2. An M+C plan may be a coordinated care plan (with or without point of service options), a combination of an M+C medical savings account (MSA) plan and a contribution into an M+C MSA established in accordance with 42 CFR part 422.262, or an M+C private fee-for-service plan. See 42 C.F.R. 422.4(a).

MALNUTRITION

A health problem caused by the lack (or too much) of needed nutrients.

MAMMOGRAM

A special x-ray of the breasts. Medicare covers the cost of a mammogram once a year for women over 40.

MANAGED CARE

Includes Health Maintenance Organizations (HMO), Competitive Medical Plans (CMP), and other plans that provide health services on a prepayment basis, which is based either on cost or risk, depending on the type of contract they have with Medicare. See also "Medicare+Choice".

MANAGED CARE ORGANIZATION

Managed Care Organizations are entities that serve Medicare or Medicaid beneficiaries on a risk basis through a network of employed or affiliated providers. Stands for Managed Care Organization. The term generally includes HMOs, PPOs, and Point of Service plans. In the Medicaid world, other organizations may set up managed care programs to respond to Medicaid managed care. These organizations include Federally Qualified Health Centers, integrated delivery systems, and public health clinics. Is a health maintenance organization, an eligible organization with a contract under 1876 or a Medicare-Choice organization, a provider-sponsored organization, or any other private or public organization, which meets the requirements of 1902 (w) to provide comprehensive services.

MANAGED CARE PAYMENT SUSPENSION

See Suspension of Payments Includes Health Maintenance Organizations (HMO), Competitive Medical Plans (CMP), and other plans that provide health services on a prepayment basis, which is based either on cost or risk, depending on the type of contract they have with Medicare. See also "Medicare+Choice."

MANAGED CARE PLAN

In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan?s list except in an emergency. Plans must cover all Medicare Part A and Part B health care. Some managed care plans cover extra benefits, like extra days in the hospital. In most cases, a type of Medicare Advantage Plan that is available in some areas of the country. Your costs may be lower than in the Original Medicare Plan.

MANAGED CARE PLAN WITH A POINT OF SERVICE OPTION (POS)

A managed care plan that lets you use doctors and hospitals outside the plan for an additional cost. (See Medicare Managed Care Plan.)

MANAGED CARE SYSTEM

Integrates the financing and delivery of appropriate health care services to covered individuals by means of: arrangements with selected providers to furnish a comprehensive set of health care services to members, explicit criteria for the selection of health care provides, and significant financial incentives for members to use providers and procedures associated with the plan. Managed care plans typically are labeled as HMOs (staff, group, IPA, and mixed models), PPOs, or Point of Service plans. Managed care services are reimbursed via a variety of methods including capitation, fee for service, and a combination of the two.

MANDATORY SPENDING

Outlays for entitlement programs (Medicare and Medicaid) that are not subject to the Federal appropriations process.

MANDATORY SUPPLEMENTAL BENEFITS

Services not covered by Medicare that enrollees must purchase as a condition of enrollment in a plan. Usually, those services are paid for by premiums and/or cost sharing. Mandatory supplemental benefits can be different for each Medicare Advantage plan. Medicare Advantage Plans must ensure that any particular group of Medicare beneficiaries does not use mandatory supplemental benefits to discourage enrollment.

MANUAL CLAIM REVIEW

Review, pre- or postpayment, that requires the intervention of PSC personnel.

MANUAL TRANSMITTALS

Manual transmittals announce policy revisions. National coverage determinations are announced in transmittals for the Medicare National Coverage Determinations Manual. Changes to Local Medical Review Policy are announced in transmittals for the Medicare Program Integrity Manual.

MARKET BASKET

See "Hospital market basket."

MASS IMMUNIZATION CENTER

A location where providers administer pneumococcal pneumonia and influenza virus vaccination and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as a public health center, pharmacy, or mall but may include a physician's office setting (4408.8, Part 3 of MCM).

MATERIAL WEAKNESS

A serious flaw in management controls requiring high-priority corrective action.

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.

MAXIMUM ENROLLEE OUT-OF-POCKET COSTS

The beneficiary's maximum dollar liability amount for a specified period.

MAXIMUM PLAN BENEFIT COVERAGE

The maximum dollar amount per period that a plan will insure. This is only applicable for service categories where there are enhanced benefits being offered by the plan, because Medicare coverage does not allow a Maximum Plan Benefit Coverage expenditure limit.

MAXIMUM TAX BASE

Annual dollar amount above which earnings in employment covered under the HI program are not taxable. Beginning in 1994, the maximum tax base is eliminated under HI.

MAXIMUM TAXABLE AMOUNT OF ANNUAL EARNINGS

See "Maximum tax base."

MCO/PHP STANDARDS

These are standards that States set for plan structure, operations, and the internal quality improvement/assurance system that each MCO/PHP must have in order to participate in the Medicaid program.

MEASUREMENT

The systematic process of data collection, repeated over time or at a single point in time.

MEDIATE

To settle differences between two parties.

MEDICAID

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

MEDICAID MANAGEMENT INFORMATION SYSTEM

A CMS approved system that supports the operation of the Medicaid program. The MMIS includes the following types of sub-systems or files: recipient eligibility, Medicaid provider, claims processing, pricing, SURS, MARS, and potentially encounter processing.

MEDICAID MCO

A Medicaid MCO provides comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

MEDICAID-ONLY MCO

A Medicaid-only MCO is an MCO that provides comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

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.

MEDICAL INSURANCE (PART B)

Medicare medical insurance that helps pay for doctors? services, outpatient hospital care, durable medical equipment, and some medical services that aren?t covered by Part A.

MEDICAL RECORDS INSTITUTE

An organization that promotes the development and acceptance of electronic health care record systems.

MEDICAL REVIEW/UTILIZATION REVIEW

Contractor reviews of Medicare claims to ensure that the service was necessary and appropriate.

MEDICAL UNDERWRITING

The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre-existing conditions (if your State law allows it), and how much to charge you for that insurance.

MEDICALLY NECESSARY

Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and aren?t mainly for the convenience of you or your doctor.

MEDICARE

The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).

MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) permitted the Centers for Medicare & Medicaid Services (CMS) to consolidate the Fiscal Intermediary (Part A) and Contractor (Part B) systems into a new system administered by Medicare Administrative Contractors (MACs), covering both Part A and Part B claims in one or more geographic jurisdictions.

MEDICARE ADVANTAGE PLAN

A Medicare program that gives you more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (unless certain exceptions apply). Medicare Advantage Plans used to be called Medicare + Choice Plans.

MEDICARE BENEFITS

Health insurance available under Medicare Part A and Part B through the traditional fee-forservice payment system.

MEDICARE BENEFITS NOTICE

A notice you get after your doctor files a claim for Part A services in the Original Medicare Plan. It says what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. You might also get an Explanation of Medicare Benefits (EOMB) for Part B services or a Medicare Summary Notice (MSN). (See Explanation of Medicare Benefits; Medicare Summary Notice.)

MEDICARE CARRIER

A private company that contracts with Medicare to pay Part B bills.

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 COORDINATION OF BENEFITS CONTRACTOR

A Medicare contractor who collects and manages information on other types of insurance or coverage that pay before Medicare. Some examples of other types of insurance or coverage are: Group Health Coverage, Retiree Coverage, Workers? Compensation, No-fault or Liability insurance, Veterans? benefits, TRICARE, Federal Black Lung Program, and COBRA.

MEDICARE COVERAGE

Made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). (See Medicare Part A (Hospital Insurance); Medicare Part B (Medical Insurance).)

MEDICARE COVERAGE DOCUMENTS (MCDS)

Documents that are published by CMS that help to relay information that is related to coverage on a national level.

MEDICARE DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER

A Medicare contractor that was responsible for administering Durable Medical Equipment (DME) benefits for a region. The term DME MAC has replaced the term DMERC.

MEDICARE ECONOMIC INDEX

An index often used in the calculation of the increases in the prevailing charge levels that help to determine allowed charges for physician services. In 1992 and later, this index is considered in connection with the update factor for the physician fee schedule.

Medicare Evidence Development & Coverage Advisory Committee (MEDCAC)(formerly know as MCAC)

The MEDCAC (formerly know as MCAC) advises CMS on whether specific medical items and services are reasonable and necessary under Medicare law. They perform this task via a careful review and discussion of specific clinical and scientific issues in an open and public forum. The MEDCAC (formerly know as MCAC) is advisory in nature, with the final decision on all issues resting with CMS. Accordingly, the advice rendered by the MEDCAC (formerly know as MCAC) is most useful when it results from a process of full scientific inquiry and thoughtful discussion, in an open forum, with careful framing of recommendations and clear identification of the basis of those recommendations.

The MEDCAC (formerly know as MCAC) is used to supplement CMS's internal expertise and to ensure an unbiased and contemporary consideration of "state of the art" technology and science. Accordingly, MEDCAC (formerly know as MCAC) members are valued for their background, education, and expertise in a wide variety of scientific, clinical, and other related fields. In composing the MEDCAC (formerly know as MCAC), CMS was diligent in pursuing ethnic, gender, geographic, and other diverse views, and to carefully screen each member to determine potential conflicts of interest.

MEDICARE HANDBOOK

The Medicare Handbook provides information on such things as how to file a claim and what type of care is covered under the Medicare program. This handbook is given to all beneficiaries when first enrolled in the program.

MEDICARE MANAGED CARE PLAN

A type of Medicare Advantage Plan that is available in some areas of the country. In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan?s list. Plans must cover all Medicare Part A and Part B health care. Some managed care plans cover extras, like prescription drugs. Your costs may be lower than in the Original Medicare Plan.

MEDICARE MEDICAL SAVINGS ACCOUNT PLAN (MSA)

A Medicare health plan option made up of two parts. One part is a Medicare MSA Health Insurance Policy with a high deductible. The other part is a special savings account where Medicare deposits money to help you pay your medical bills.

MEDICARE NATIONAL COVERAGE DETERMINATIONS MANUAL

(Formerly the Coverage Issues Manual) The National Coverage Determinations Manual contains implementing instructions for National Coverage Determinations. The manual includes information whether specific medical items, services, treatment procedures, or technologies are paid for under the Medicare program on a national level.

MEDICARE PART A (HOSPITAL INSURANCE)

Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

MEDICARE PART A FISCAL INTERMEDIARY

A Medicare contractor that administers the Medicare Part A (institutional) benefits for a given region.

MEDICARE PART B (MEDICAL INSURANCE)

Medicare medical insurance that helps pay for doctors? services, outpatient hospital care, durable medical equipment, and some medical services that aren?t covered by Part A.

MEDICARE PART B CARRIER

A Medicare contractor that administers the Medicare Part B (Professional) benefits for a given region.

MEDICARE PART B PREMIUM REDUCTION AMOUNT

Since CY 2003, MCOs are able to use their adjusted excess to reduce the Medicare Part B premium for beneficiaries. When offering this benefit, a plan cannot reduce its payment by more than 125 percent of the Medicare Part B premium. In order to calculate the Part B premium reduction amount, the PBP system must multiply the number entered in the "indicate your MCO plan payment reduction amount, per member" field by 80 percent. The resulting number is the Part B premium reduction amount for each member in that particular plan (rounded to the nearest multiple of 10 cents).

MEDICARE PAYMENT ADVISORY COMMISSION

A commission established by Congress in the Balanced Budget Act of 1997 to replace the Prospective Payment Assessment Commission and the Physician Payment Review Commission. MedPAC is directed to provide the Congress with advice and recommendations on policies affecting the Medicare program.

MEDICARE PREFERRED PROVIDER ORGANIZATION (PPO) PLAN

A type of Medicare Advantage Plan in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

MEDICARE PREMIUM COLLECTION CENTER (MPCC)

The contractor that handles all Medicare direct billing payments for direct billed beneficiaries. MPCC is located in Pittsburgh, Pennsylvania.

MEDICARE PRIVATE FEE-FOR-SERVICE PLAN

A type of Medicare Advantage plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan?s payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn?t cover.

MEDICARE PROGRAM INTEGRITY MANUAL

Medicare instruction to medical review contractors, which is designed to identify and address fraud, waste, and abuse.

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.

MEDICARE SAVINGS PROGRAM

Medicaid programs that help pay some or all Medicare premiums and deductibles.

MEDICARE SAVINGS PROGRAMS

There are programs that help millions of people with Medicare save money each year. States have programs for people with limited incomes and resources that pay Medicare premiums. Some programs may also pay Medicare deductibles and coinsurance. You can apply for these programs if: You have Medicare Part A (Hospital Insurance). (If you are eligible for Medicare Part A but don?t think you can afford it, there is a program that may pay the Medicare Part A premium for you.), you are an individual with resources of $4,000 or less, or are a couple with resources of $6,000 or less. Resources include money in a savings or checking account, stocks, or bonds and You are an individual with a monthly income of less than $1,031, or a couple with a monthly income of less than $1,384. Income limits will change slightly in 2004. If you live in Hawaii or Alaska, income limits are slightly higher. Note: If your income is less than the amounts listed above, you may qualify for Medicaid.

MEDICARE SECONDARY PAYER

A statutory requirement that private insurers providing general health insurance coverage to Medicare beneficiaries pay beneficiary claims as primary payers.

MEDICARE SECONDARY PAYER

Any situation where another payer or insurer pays your medical bills before Medicare.

MEDICARE SELECT

A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

MEDICARE SUMMARY NOTICE (MSN)

A notice you get after the doctor or provider files a claim for Part A and Part B services in the Original Medicare Plan. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.

MEDICARE SUPPLEMENT INSURANCE

Medicare supplement insurance is a Medigap policy. It is sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. Except in Minnesota, Massachusetts, and Wisconsin, there are 10 standardized policies labeled Plan A through Plan J. Medigap policies only work with the Original Medicare Plan. (See Gaps and Medigap Policy.)

MEDICARE TRUST FUNDS

Treasury accounts established by the Social Security Act for the receipt of revenues, maintenance of reserves, and disbursement of payments for the HI and SMI programs.

MEDICARE+CHOICE

A Medicare program that gives you more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease.

MEDICARE+CHOICE PLAN

A health plan, such as a Medicare managed care plan or Private Fee-for-Service plan offered by a private company and approved by Medicare. An alternative to the Original Medicare Plan.

MEDICARE-APPROVED AMOUNT

In the Original Medicare Plan, this is the Medicare payment amount for an item or service. This is the amount a doctor or supplier is paid by Medicare and you for a service or supply. It may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the ?Approved Charge.?

MEDIGAP POLICY

A Medicare supplement insurance policy sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. Except in Massachusetts, Minnesota and Wisconsin, there are 10 standardized plans labeled Plan A through Plan J. Medigap policies only work with the Original Medicare Plan. (See Gaps.)

MEMORANDUM OF UNDERSTANDING

A document providing a general description of the responsibilities that are to be assumed by two or more parties in their pursuit of some goal(s). More specific information may be provided in an associated SOW.

MEMORANDUM OF UNDERSTANDING

An instrument used when agencies enter into a joint project in which they each contribute their own resources in which the scope of work is very broad and not specific to any one project; or in which there is no exchange of goods or services between the participating agencies.

MILITARY SERVICE WAGE CREDITS

Credits recognizing that military personnel receive other cash payments and wages in kind (such as food and shelter) in addition to their basic pay. Noncontributory wage credits of $160 are provided for each month of active military service from September 16, 1940 through December 31, 1956. For years after 1956, the basic pay of military personnel is covered under the Social Security program on a contributory basis. In addition to contributory credits for basic pay, noncontributory wage credits of $300 are granted for each calendar quarter in which a person receives pay for military service from January 1957 through December 1977. Deemed wage credits of $100 are granted for each $300 of military wages in years after 1977. (The maximum credits allowed in any calendar year are $1,200.) See also "Quinquennial military service determinations and adjustments."

MILITARY TREATMENT FACILITY

A medical facility operated by one or more of the Uniformed Services. A Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Services (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).

MINIMUM SCOPE OF DISCLOSURE

The principle that, to the extent practical, individually identifiable health information should only be disclosed to the extent needed to support the purpose of the disclosure.

MODALITY

Methods of treatment for kidney failure/ESRD. Modality types include transplant, hemodialysis, and peritoneal dialysis.

MODIFIED AVERAGE-COST METHOD

Under this system of calculating summary measures, the actuarial balance is defined as the difference between the arithmetic means of the annual cost rates and the annual income rates, with an adjustment included to account for the offsets to cost that are due to (1) the starting trust fund balance and (2) interest earned on the trust fund.

MODIFY OR MODIFICATION

Under HIPAA, this is a change adopted by the Secretary, through regulation, to a standard or an implementation specification.

MONITORING

A planned, systematic, and ongoing process to gather and organize data, and aggregate results in order to evaluate performance.

MONITORING OF MCO/PHP STANDARDS

Activities related to the monitoring of standards that have been set for plan structure, operations, and quality improvement/assurance to determine that standards have been established, implemented, adhered to, etc.

MORBIDITY

A diseased state, often used in the context of a "morbidity rate" (i.e. The rate of disease or proportion of diseased people in a population). In common clinical usage, any disease state, including diagnosis and complications is referred to as morbidity.

MORBIDITY RATE

The rate of illness in a population. The number of people ill during a time period divided by the number of people in the total population.

MORTALITY RATE

The death rate often made explicit for a particular characteristic (e.g. gender, sex, or specific cause of death). Mortality rate contains three essential elements: the number of people in a population exposed to the risk of death (denominator), a time factor, and the number of deaths occurring in the exposed population during a certain time period (the numerator).

MULTI-EMPLOYER GROUP HEALTH PLAN

A group health plan that is sponsored jointly by two or more employers or by employers and employee organizations.

MULTI-EMPLOYER PLAN

A group health plan that is sponsored jointly by two or more employers or by employers and unions.

MULTIPLE EMPLOYER PLAN

A health plan sponsored by two or more employers. These are generally plans that are offered through membership in an association or a trade group.


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Term Definition
NATIONAL ASSOCIATION OF HEALTH DATA ORGANIZATIONS

A group that promotes the development and improvement of state and national health information systems.

NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS

An association of the insurance commissioners of the states and territories.

NATIONAL ASSOCIATION OF STATE MEDICAID DIRECTORS

An association of state Medicaid directors. NASMD is affiliated with the American Public Health Human Services Association (APHSA).

NATIONAL CENTER FOR HEALTH STATISTICS

A federal organization within the CDC that collects, analyzes, and distributes health care statistics. The NCHS maintains the ICD-n-CM codes.

NATIONAL COMMITTEE FOR QUALITY ASSURANCE

An organization that accredits managed care plans, or Health Maintenance Organizations (HMOs). In the future, the NCQA may play a role in certifying these organizations' compliance with the HIPAA A/S requirements. The NCQA also maintains the Health Employer Data and Information Set (HEDIS).

NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)

A non-profit organization that accredits and measures the quality of care in Medicare health plans. NCQA does this by using the Health Employer Data and Information Set (HEDIS) data reporting system. (See Health Employer Data and Information Set (HEDIS).)

NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS

A Federal advisory body within HHS that advises the Secretary regarding potential changes to the HIPAA standards.

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 COVERAGE ANALYSES (NCA)

Numerous documents support the national coverage determination process. They include tracking sheets to inform the public of the issues under consideration and the status (i.e., Pending, Closed) of the review, information about and results of MEDCAC (formerly know as MCAC) meetings, Technology Assessments, and Decision Memoranda that announce CMS's intention to issue an NCD. These documents, along with the compilation of medical and scientific information currently available, any FDA safety and efficacy data, clinical trial information, etc., provide the rationale behind the evidence-based NCDs.

NATIONAL COVERAGE DETERMINATIONS (NCDS)

An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision (see LCD). Prior to an NCD taking effect, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to our claims-processing contractors. That issuance, which includes an effective date and implementation date, is the NCD. If appropriate, the Agency must also change billing and claims processing systems and issue related instructions to allow for payment. The NCD will be published in the Medicare National Coverage Determinations Manual. An NCD becomes effective as of the date listed in the transmittal that announces the manual revision.

NATIONAL COVERAGE POLICY

A policy developed by CMS that indicates whether and under what circumstances certain services are covered under the Medicare program. It is published in CMS regulations, published in the Federal Register as a final notice, contained in a CMS ruling, or issued as a program instruction.

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 EMPLOYER ID

A system for uniquely identifying all sponsors of health care benefits.

NATIONAL HEALTH INFORMATION INFRASTRUCTURE

This is a healthcare-specific lane on the Information Superhighway, as described in the National Information Infrastructure (NII) initiative. Conceptually, this includes the HIPAA A/S initiatives.

NATIONAL IMPROVEMENT PROJECTS

HCQIP projects developed by a group consisting of representatives of some or all of the following groups: CMS, Public Health Service, Networks, renal provider, and consumer communities. The object is to use statistical analysis to identify better patterns of care and outcomes, and to feed the results of the analysis back into the provider community to improve the quality of care provided to renal Medicare beneficiaries. Each project will have a particular clinical focus.

NATIONAL MEDIAN CHARGE

The national median charge is the exact middle amount of the amounts charged for the same service. This means that half of the hospitals and community mental health centers charged more than this amount and the other half charged less than this amount for the same service.

NATIONAL PATIENT ID

A system for uniquely identifying all recipients of health care services. This is sometimes referred to as the National Individual Identifier (NII), or as the Healthcare ID.

NATIONAL PAYER ID

A system for uniquely identifying all organizations that pay for health care services. Also known as Health Plan ID, or Plan ID.

NATIONAL PLAN AND PROVIDER ENUMERATION SYSTEM (NPPES)

The system that uniquely identifies a health care provider (as defined at 45 CFR 160.103) and assigns it an NPI. The system is designed with the future capability to also enumerate health plans once the Secretary has adopted a standard unique health identifier for health plans.

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.

NATIONAL STANDARD PER VISIT RATES

National rates for each 6 home health disciplines based on historical claims data. Used in payment of LUPAs and calculation of outliers.

NATIONAL UNIFORM BILLING COMMITTEE

An organization, chaired and hosted by the American Hospital Association, that maintains the UB-92 hardcopy institutional billing form and the data element specifications for both the hardcopy form and the 192-byte UB-92 flat file EMC format. The NUBC has a formal consultative role under HIPAA for all transactions affecting institutional health care services.

NATIONAL UNIFORM CLAIM COMMITTEE

An organization, chaired and hosted by the American Medical Association, that maintains the HCFA-1500 claim form and a set of data element specifications for professional claims submission via the HCFA-1500 claim form, the Professional EMC NSF, and the X12 837. The NUCC also maintains the Provider Taxonomy Codes and has a formal consultative role under HIPAA for all transactions affecting non-dental non-institutional professional health care services.

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

An NCPDP standard designed for use by high-volume dispensers of pharmaceuticals, such as retail pharmacies. Use of Version 5.1 of this standard has been mandated under HIPAA.

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.

NEBULIZERS

Equipment to give medicine in a mist form to your lungs.

NEGLECT

When care takers do not give a person they care for the goods or services needed to avoid harm or illness.

NETWORK

A group of doctors, hospitals, pharmacies, and other health care experts hired by a health plan to take care of its members.

NNPI ENUMERATOR

An organization under contract with the Centers for Medicare & Medicaid Services whose responsibility includes, but is not limited to, the processing of applications for, and deactivations of, National Provider Identifiers (NPIs), and the processing of changes of information to health care providers' records contained in the National Plan and Provider Enumeration System (NPPES). The NPI Enumerator assists health care providers in taking the above actions and resolves any problems in the processing of those actions.

NO-FAULT INSURANCE

No-fault insurance is insurance that pays for health care services resulting from injury to you or damage to your property regardless of who is at fault for causing the accident.

NONCONTRIBUTORY OR DEEMED WAGE CREDITS

Wages and wages in kind that were not subject to the HI tax but are deemed as having been. Deemed wage credits exist for the purposes of (1) determining HI program eligibility for individuals who might not be eligible for HI coverage without payment of a premium were it not for the deemed wage credits; and (2) calculating reimbursement due the HI trust fund from the general fund of the Treasury. The first purpose applies in the case of providing coverage to persons during the transitional periods when the HI program began and when it was expanded to cover federal employees; both purposes apply in the cases of military service wage credits (see "Military service wage credits" and "Quinquennial military service determinations and adjustments") and deemed wage credits granted for the internment of persons of Japanese ancestry during World War II.

NON-COVERED SERVICE

The service:

  • does not meet the requirements of a Medicare benefit category,
  • Is statutorily excluded from coverage on ground other than 1862(a)(1), or
  • is not reasonable and necessary under 1862 (a)(1).
NON-ENTITY ASSETS

Assets that are held by an entity but are not available to the entity. These are also amounts that, when collected, cannot be spent by the reporting entity.

NON-FEDERAL AGENCY

A State or local government agency that receives records contained in a system of records from a Federal agency to be used in a matching program.

NON-FORMULARY DRUGS

Drugs not on a plan-approved list.

NONPARTICIPATING PHYSICIAN

A doctor or supplier who does not accept assignment on all Medicare claims. (See Assignment.)

NORTH CAROLINA HEALTHCARE INFORMATION AND COMMUNICATIONS ALLIANCE

An organization that promotes the advancement and integration of information technology into the health care industry.

NOTICE OF INTENT

A document that describes a subject area for which the Federal Government is considering developing regulations. It may describe the presumably relevant considerations and invite comments from interested parties. These comments can then be used in developing an NPRM or a final regulation.

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.

NPI REGISTRY

A publicly available, Internet-based real-time query database that displays publicly available health care provider data from the NPPES in response to a user?s query.

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.

NUBC EDI TAG

The NUBC EDI Technical Advisory Group, which coordinates issues affecting both the NUBC and the X12 standards.

NURSE PRACTITIONER

A nurse who has 2 or more years of advanced training and has passed a special exam. A nurse practitioner often works with a doctor and can do some of the same things a doctor does.

NURSING FACILITY

A facility which primarily provides to residents skilled nursing care and relate services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health related care services above the level of custodial care to other than mentally retarded individuals.

NURSING FACILITY

A facility which primarily provides skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health related care services above the level of custodial care to other than mentally retarded individuals.

NURSING HOME

A residence that provides a room, meals, and help with activities of daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance.

NUTRITION

Getting enough of the right foods with vitamins and minerals a body needs to stay healthy. Malnutrition, or the lack of proper nutrition, can be a serious problem for older people.


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Term Definition
OBLIGATION

Budgeted funds committed to be spent.

OCCUPATIONAL THERAPY

Services given to help you return to usual activities (such as bathing, preparing meals, housekeeping) after illness.

OFFICE

Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

OFFICE FOR CIVIL RIGHTS

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

OFFICE OF MANAGEMENT & BUDGET

A Federal Government agency that has a major role in reviewing proposed Federal regulations.

OFFSET

The recovery by Medicare of a non-Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness. (Examples are Public Health Service debts or Medicaid debts recovered by CMS). (See also Recoupment and Suspension of Payments.)

OLD-AGE, SURVIVORS, AND DISABILITY INSURANCE

The Social Security programs that pay for (1) monthly cash benefits to retired-worker (old-age) beneficiaries, their spouses and children, and survivors of deceased insured workers (OASI); and (2) monthly cash benefits to disabled-worker beneficiaries and their spouses and children, and for providing rehabilitation services to the disabled (DI).

OMBUDSMAN

An ombudsman is an individual who assists enrollees in resolving problems they may have with their MCO/PHP. An ombudsman is a neutral party who works with the enrollee, the MCO/PHP, and the provider (as appropriate) to resolve individual enrollee problems.

OMBUDSMAN

An advocate (supporter) who works to solve problems between residents and nursing homes, as well as assisted living facilities. Also called "Long-term Care Ombudsman."

ON-SITE REVIEWS

Reviews performed on-site at the MCO/PHP health care delivery system sites to assess the physical resources and operational practices in place to deliver health care.

OPEN ENROLLMENT PERIOD

A one-time-only six month period when you can buy any Medigap policy you want that is sold in your State. It starts in the first month that you are covered under Medicare Part B and you are age 65 or older. During this period, you can?t be denied coverage or charged more due to past or present health problems.

OPEN SYSTEM INTERCONNECTION

A multi-layer ISO data communications standard. Level Seven of this standard is industry-specific, and HL7 is responsible for specifying the level seven OSI standards for the health industry.

OPTIONAL SUPPLEMENTAL BENEFITS

Services not covered by Medicare that enrollees can choose to buy or reject. Enrollees that choose such benefits pay for them directly, usually in the form of premiums and/or cost sharing. Those services can be grouped or offered individually and can be different for each M+C plan offered.

ORGAN

Organ means a human kidney, liver, heart, or pancreas.

ORGAN PROCUREMENT

The process of acquiring donor kidneys in the ESRD program.

ORGAN PROCUREMENT ORGANIZATION

An organization that performs or coordinates the retrieval, preservation, and transportation of organs and maintains a system of locating prospective recipients for available organs.

ORGANIZATIONAL DETERMINATION

A health plan's decision on whether to pay all or part of a bill, or to give medical services, after you file an appeal. If the decision is not in your favor, the plan must give you a written notice. This notice must give a reason for the denial and a description of steps in the appeals process. (See Appeals Process.)

ORIGINAL MEDICARE PLAN

A pay-per-visit health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

OTHER MANAGED CARE ARRANGEMENT

Other Managed Care Arrangement is used if the plan is not considered either a PCCM, PHP, Comprehensive MCO, Medicaid-only MCO, or HIO.

OTHER UNLISTED FACILITY

Other service facilities not previously identified.

OUT OF AREA

Services provided to enrollees by providers that have no contractual or other relationship with M+C Organizations.

OUT OF NETWORK BENEFIT

Generally, an out-of-network benefit provides a beneficiary with the option to access plan services outside of the plan?s contracted network of providers. In some cases, a beneficiary?s out-of-pocket costs may be higher for an out-of-network benefit.

OUTCOME

The result of performance (or nonperformance) of a function or process.

OUTCOME AND ASSESSMENT INFORMATION SET

A group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI). This assessment is performed on every patient receiving services of Home Health agencies that are approved to participate in the Medicare and/or Medicaid programs.

OUTCOME DATA

Data that measure the health status of people enrolled in managed care resulting from specific medical and health interventions (e.g. the incident of measles among plan enrollees during the calendar year).

OUTCOME INDICATOR

An indicator that assesses what happens or does not happen to a patient following a process; agreed upon desired patient characteristics to be achieved; undesired patient conditions to be avoided.

OUTLAY

The issuance of checks, disbursement of cash, or electronic transfer of funds made to liquidate an expense regardless of the fiscal year the service was provided or the expense was incurred. When used in the discussion of the Medicaid program, outlays refer to amounts advanced to the States for Medicaid benefits.

OUTLIER

Additions to a full episode payment in cases where costs of services delivered are estimated exceed a fixed loss threshold. HH PPS outliers are computed as part of Medicare claims payment by Pricer Software.

OUT-OF-POCKET COSTS

Health care costs that you must pay on your own because they are not covered by Medicare or other insurance.

OUTPATIENT CARE

Medical or surgical care that does not include an overnight hospital stay.

OUTPATIENT HOSPITAL

A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. Part of the Hospital providing services covered by SMI, including services in an emergency room or outpatient clinic, ambulatory surgical procedures, medical supplies such as splints, laboratory tests billed by the hospital, etc.

OUTPATIENT HOSPITAL SERVICES (MEDICARE)*

Medicare or surgical care that Medicare Part B helps pay for and does not include an overnight hospital stay, including:

  • blood transfusions;
  • certain drugs;
  • hospital billed laboratory tests;
  • mental health care;
  • medical supplies such as splints and casts;
  • emergency room or outpatient clinic, including same day surgery; and
  • emergency room or outpatient clinic, including same day surgery; and
  • x-rays and other radiation services.
OUTPATIENT PROSPECTIVE PAYMENT SYSTEM

The way that Medicare pays for most outpatient services at hospitals or community mental health centers under Medicare Part B.

OUTPATIENT SERVICES

A service you get in one day (24 hours) at a hospital outpatient department or community mental health center.

OVERPAYMENT ASSESSMENT

A decision that an incorrect amount of money has been paid for Medicare services and a determination of what that amount is.


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Term Definition
PANEL SIZE

Means the number of patients served by a physician or physician group. If the panel size is greater than 25,000 patients, then the physician group is not considered to be at substantial financial risk because the risk is spread over the large number of patients. Stop loss and beneficiary surveys would not be required.

PAP TEST

A test to check for cancer of the cervix, the opening to a woman's womb. It is done by removing cells from the cervix. The cells are then prepared so they can be seen under a microscope.

PART A (HOSPITAL INSURANCE)

Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

PART A (MEDICARE)

Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care. (See Hospital Insurance (Part A).)

PART A OF MEDICARE

Medicare Hospital Insurance also referred to as "HI." Part A is the hospital insurance portion of Medicare. It was established by 1811 of Title XVIII of the Social Security Act of 1965, as amended, and covers inpatient hospital care, skilled nursing facility care, some home health agency services, and hospice care.

PART A PREMIUM

A monthly premium paid by or on behalf of individuals who wish for and are entitled to voluntary enrollment in the Medicare HI program. These individuals are those who are aged 65 and older, are uninsured for social security or railroad retirement, and do not otherwise meet the requirements for entitlement to Part A. Disabled individuals who have exhausted other entitlement are also qualified. These individuals are those not now entitled but who have been entitled under section 226(b) of the Act, who continue to have the disabling impairment upon which their entitlement was based, and whose entitlement ended solely because the individuals had earnings that exceeded the substantial gainful activity amount (as defined in section 223(d)(4) of the Act).

PART B (MEDICAL INSURANCE)

Medicare medical insurance that helps pay for doctors? services, outpatient hospital care, durable medical equipment, and some medical services that aren?t covered by Part A.

PART B (MEDICARE)

Medicare medical insurance that helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Part A. (See Medical Insurance (Part B).)

PART B OF MEDICARE

Medicare Supplementary Medical Insurance also referred to as "SMI." Medicare insurance that pays for inpatient hospital stay, care in a skilled nursing facility, home health care, and hospice care. Part B is the supplementary or "physicians" insurance portion of Medicare. It was established by 1831 of the Title XVIII of the Social Security Act of 1965 as amended, and covers services of physicians/other suppliers, outpatient care, medical equipment and supplies, and other medical services not covered by the hospital insurance part of Medicare.

PARTIAL CAPITATION

A plan is paid for providing services to enrollees through a combination of capitation and fee for service reimbursements.

PARTIAL HOSPITALIZATION

A structured program of active treatment for psychiatric care that is more intense than the care you get in your doctor?s or therapist?s office.

PARTIALLY CAPITATED

A stipulated dollar amount established for certain health care services while other services are reimbursed on a cost or fee-for-service basis.

PARTICIPATING HOSPITALS

Those hospitals that participate in the Medicare program.

PARTICIPATING PHYSICIAN OR SUPPLIER

A doctor or supplier who agrees to accept assignment on all Medicare claims. These doctors or suppliers may bill you only for Medicare deductible and/or coinsurance amounts. (See Assignment.)

PATIENT ADVOCATE

A hospital employee whose job is to speak on a patient?s behalf and help patients get any information or services they need.

PATIENT LIFTS

Equipment to move a patient from a bed or wheelchair using your strength or a motor.

PATTERN ANALYSIS

The clinical and statistical analysis of data sets. Frequently used ESRD data sets include the PMMIS, USRDS, the core indicators, Network files, or CMS analytic files.

PAY-AS-YOU-GO FINANCING

A financing scheme in which taxes are scheduled to produce just as much income as required to pay current benefits, with trust fund assets built up only to the extent needed to prevent exhaustion of the fund by random fluctuations.

PAYER

In health care, an entity that assumes the risk of paying for medical treatments. This can be an uninsured patient, a self-insured employer, a health plan, or an HMO.

PAYERID

CMS's term for their pre-HIPAA National Payer ID initiative.

PAYMENT

Costs incurred for processing of data.

PAYMENT RATE

The total payment that a hospital or community mental health center gets when they give outpatient services to Medicare patients.

PAYMENT SAFEGUARDS

Activities to prevent and recover inappropriate Medicare benefit payments including MSP, MR/UR, provider audits, and fraud and abuse detection.

PAYMENT SUSPENSION

See Suspension of Payments.

PAYROLL TAXES

Taxes levied on the gross wages of workers.

PELVIC EXAM

An exam to check if internal female organs are normal by feeling their shape and size.

PERCENTILE

A number that corresponds to one of the equal divisions of the range of a variable in a given sample and that characterizes a value of the variable as not exceeded by a specified percentage of all the values in the sample. For example, a score higher that 97 percent of those attained is said to be in the 97th percentile.

PERFORMANCE

The way in which an individual, group, or organization carries out or accomplishes its important functions or processes.

PERFORMANCE ASSESSMENT

Involves the analysis and interpretation of performance measurement data to transform it into useful information for purposes of continuous performance improvement.

PERFORMANCE IMPROVEMENT PROJECTS

Projects that examine and seek to achieve improvement in major areas of clinical and non-clinical services. These projects are usually based on information such as enrollee characteristics, standardized measures, utilization, diagnosis and outcome information, data from surveys, grievance and appeals processes, etc. They measure performance at two periods of time to ascertain if improvement has occurred. These projects are required by the State and can be of the MCO/PHPs choosing or prescribed by the State.

PERFORMANCE MEASURE

Is information that shows how well a health plan provides a certain treatment, test, or other health care service to its members. For example, Medicare uses performance measures from NCQA?s Health Plan Employer Data and Information Set (HEDIS) to get information on how well health plans perform in quality, how easy it is to get care, and members? satisfaction with the health plan and its doctors.

PERFORMANCE MEASURES

A gauge used to assess the performance of a process or function of any organization. Quantitative or qualitative measures of the care and services delivered to enrollees (process) or the end result of that care and services (outcomes). Performance measures can be used to assess other aspects of an individual or organization's performance such as access and availability of care, utilization of care, health plan stability, beneficiary characteristics, and other structural and operational aspect of health care services. Performance measures included here may include measures calculated by the State (from encounter data or another data source), or measures submitted by the MCO/PHP.

PERIODS OF CARE (HOSPICE)

A set period of time that you can get hospice care after your doctor says that you are eligible and still need hospice care.

PERITONEAL DIALYSIS

A procedure that introduces dialysate into the abdominal cavity to remove waste products through the peritoneum (a membrane which surrounds the intestines and other organs in the abdominal cavity). It functions in a manner similar to that of the artificial semi permeable membrane in the hemodialysis machine. Three forms of peritoneal dialysis are continuous ambulatory peritoneal dialysis, continuous cycling peritoneal dialysis, and intermittent peritoneal dialysis.

PERITONEAL DIALYSIS (PD)

PD uses a cleaning solution, called dialysate, that flows through a special tube into your abdomen. After a few hours, the dialysate gets drained from your abdomen, taking the wastes from your blood with it. Then you fill your abdomen with fresh dialysate and the cleaning process begins again. This treatment can be done at home, at your workplace, or at another convenient location (See dialysis and hemodialysis.).

PERSONAL CARE

Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in and out of bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops. The Medicare home health benefit does pay for personal care services.

PHYSICAL THERAPY

Treatment of injury and disease by mechanical means, such as heat, light, exercise, and massage.

PHYSICIAN ASSISTANT (PA)

A person who has 2 or more years of advanced training and has passed a special exam. A physician assistant works with a doctor and can do some of the things a doctor does.

PHYSICIAN GROUP

A partnership, association, corporation, individual practice association (IPA), or other group that distributes income from the practice among members. An IPA is considered to be a physician group only if it is composed of individual physicians and has no subcontracts with other physician groups.

PHYSICIAN INCENTIVE PLAN

Any compensation arrangement at any contracting level between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to Medicare or Medicaid enrollees in the MCO. MCOs must disclose physician incentive plans between the MCO itself and individual physicians and groups and, also, between groups or intermediate entities (e.g., certain IPAs, Physician-Hospital Organizations) and individual physicians and groups. See 42 C.F.R. 422.208(a).

PHYSICIAN SERVICES

Services provided by an individual licensed under state law to practice medicine or osteopathy. Physician services given while in the hospital that appear on the hospital bill are not included.

PLAN ID

See National Payer ID.

PLAN OF CARE

Your doctor's written plan saying what kind of services and care you need for your health problem.

PLAN SPONSOR

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

POINT OF SERVICE (POS)

An additional, mandatory supplemental, or optional supplemental benefit that allows the enrollee the option of receiving specified services outside of the plan's provider network.

POINT-OF-SERVICE (POS)

A Medicare Managed Care Plan option that lets you use doctors and hospitals outside the plan for an additional cost.

POLICY ADVISORY GROUP

A generic name for many work groups at WEDI and elsewhere.

POSTPAYMENT REVIEW

The review of a claim after a determination and payment has been made to the provider or beneficiary.

POTENTIAL FRAUD CASE

A case developed after the PSC has substantiated an allegation of fraud.

POTENTIAL PAYMENTS

Means the maximum anticipated total payments (based on the most recent year's utilization and experience and any current or anticipated factors that may affect payment amounts) that could be received if use or costs of referral services were low enough. These payments include amounts paid for services furnished or referred by the physician/group, plus amounts paid for administrative costs. The only payments not included in potential payments are bonuses or other compensation not based on referrals (e.g., bonuses based on patient satisfaction or other quality of care factors).

POWER OF ATTORNEY

A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a health care proxy, appointment of health care agent or a durable power of attorney for health care.

PRE-EXISTING CONDITION

A health problem you had before the date that a new insurance policy starts.

PREFERRED PROVIDER ORGANIZATION

An M+CO coordinated care plan that: (a) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (b) provides for reimbursement for all covered benefits regardless of whether the benefits are provided with the network of providers; and (c) is offered by an organization that is not licensed or organized under State law as an HMO. See Social Security Act Section 1852(e)(2)(D), 42 U.S.C. 139w-22(e)(2)(D).

PREFERRED PROVIDER ORGANIZATION (PPO)

A managed care in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

PREFERRED PROVIDER ORGANIZATION (PPO) PLAN

A type of Medicare Advantage Plan in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

PREMIUM SURCHARGE

The standard Medicare Part B premium will go up ten percent for each full 12-month period (beginning with the first month after the end of your Initial Enrollment Period) that you could have had Medicare Part B but didn?t take it. The additional premium amount is called a ?premium surcharge.? There will be a surcharge for Part D also.

PREPAID HEALTH PLAN

A prepaid managed care entity that provides less than comprehensive services on an at risk basis or one that provides any benefit package on a non-risk basis.

PREPAYMENT REVIEW

The review of claims prior to determination and payment.

PRESENT VALUE

The present value of a future stream of payments is the lump-sum amount that, if invested today, together with interest earnings would be just enough to meet each of the payments as it fell due. At the time of the last payment, the invested fund would be exactly zero.

PREVALENCE

The number of existing cases of a disease or condition in a given population at a specific time.

PREVENTIVE SERVICES

Health care to keep you healthy or to prevent illness (for example, Pap tests, pelvic exams, flu shots, and screening mammograms).

PRICER

Software modules in Medicare claims processing systems, specific to certain benefits, used in pricing claims, most often under prospective payment systems.

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.

PRIMARY CARE

A basic level of care usually given by doctors who work with general and family medicine, internal medicine (internists), pregnant women (obstetricians), and children (pediatricians). A nurse practitioner (NP), a State licensed registered nurse with special training, can also provide this basic level of health care.

PRIMARY CARE CASE MANAGEMENT PROVIDER

A PCCM provider is a provider (usually a physician, physician group practice, or an entity employing or having other arrangements with such physicians, but sometimes also including nurse practitioners, nurse midwives, or physician assistants) who contracts to locate, coordinate, and monitor covered primary care (and sometimes additional services). This category includes any PCCMs and those PHPs which act as PCCMs.

PRIMARY CARE DOCTOR

A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare managed care plans, you must see your primary care doctor before you see any other health care provider.

PRIMARY CASE MANAGEMENT

A program where the State contracts directly with primary care providers who agree to be responsible for the provision and/or coordination of medical services to Medicaid recipients under their care. Currently, most PCCM programs pay the primary care physician a monthly case management fee in addition to reimbursing services on a fee-for-service basis.

PRIMARY PAYER

An insurance policy, plan, or program that pays first on a claim for medical care. This could be Medicare or other health insurance.

PRIVACY ACT OF 1974

Without the written consent of the individual, the Privacy Act prohibits release of protected information maintained in a system of records unless of 1 of the 12 disclosure provisions applies.

PRIVATE CONTRACT

A contract between you and a doctor, podiatrist, dentist, or optometrist who has decided not to offer services through the Medicare program. This doctor can?t bill Medicare for any service or supplies given to you and all his/her other Medicare patients for at least 2 years. There are no limits on what you can be charged for services under a private contract. You must pay the full amount of the bill.

PRIVATE FEE-FOR-SERVICE PLAN

A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan?s payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn?t cover.

PROCEDURE

Something done to fix a health problem or to learn more about it. For example, surgery, tests, and putting in an IV (intravenous line) are procedures.

PROCESS

The goal-directed, interrelated series of actions, events, mechanisms, or steps.

PROCESS IMPROVEMENT

A methodology utilized to make improvements to a process through the use of continuous quality improvement methods.

PROCESS INDICATOR

A gauge that measures a goal-directed interrelated series of actions, events, mechanisms, or steps.

PRODUCTIVITY INVESTMENTS

Spending aimed at increasing contractor operational efficiency and productivity through improved work methods, application of technology, etc.

PROFILES

Data segregated by specific time period (e.g. quarterly, annually) and target area (e.g. facility, State) for the purpose of identifying patterns.

PROGRAM MANAGEMENT

CMS operational account. Program Management supplies the agency with the resources to administer Medicare, the Federal portion of Medicaid, and other Agency responsibilities. The components of Program Management are Medicare contractors, survey and certification, research, and administrative costs.

PROGRAM MANAGEMENT AND MEDICAL INFORMATION SYSTEM

An automated system of records that contains records primarily of current Medicare-eligible ESRD patients, but also maintains historical information on people no longer classified as ESRD patients because of death or successful transplantation or recovery of renal function. The PMMIS contains medical information on patients and the services that they received during the course of their therapy. In addition, it contains information on ESRD facilities and facility payment. Beginning January 1, 1995, the PMMIS collects information on all dialysis and kidney transplant patients.

PROGRAM SAFEGUARD CONTRACTOR

A contractor hired under this SOW.

PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

PACE combines medical, social, and long-term care services for frail people. PACE is available only in states that have chosen to offer it under Medicaid. To be eligible, you must:

  • Be 55 years old, or older,
  • Live in the service area of the PACE program,
  • Be certified as eligible for nursing home care by the appropriate state agency , and
  • Be able to live safely in the community.

The goal of PACE is to help people stay independent and live in their community as long as possible, while getting high quality care they need.

PROJECT OFFICER

An appointed person who is responsible overall for a project. A departmental person is usually appointed.

PROJECTION ERROR

Degree of variation between estimated and actual amounts.

PROS AND CONS

The good and bad parts of treatment for a health problem. For example, a medicine may help your pain (pro), but it may cause an upset stomach (con).

PROSPECTIVE PAYMENT SYSTEM

A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, DRGs for inpatient hospital services).

PROTECTED HEALTH INFORMATION

Individually identifiable health information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate. Identifies the individual or offers a reasonable basis for identification. Is created or received by a covered entity or an employer Relates to a past, present, or future physical or mental condition, provision of health care or payment for health care.

PROVIDER

Any Medicare provider (e.g., hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, physician, non-physician provider, laboratory, supplier, etc.) providing medical services covered under Medicare Part B. Any organization, institution, or individual that provides health care services to Medicare beneficiaries. Physicians, ambulatory surgical centers, and outpatient clinics are some of the providers of services covered under Medicare Part B.

PROVIDER NETWORK

The providers with which an M+C Organization contracts or makes arrangements to furnish covered health care services to Medicare enrollees under an M+C coordinated care or network MSA plan.

PROVIDER SPONSORED ORGANIZATION (PSO)

A group of doctors, hospitals, and other health care providers that agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. This type of managed care plan is run by the doctors and providers themselves, and not by an insurance company. (See Managed Care Plan.)

PROVIDER SURVEY DATA

Data collected through a survey or focus group of providers who participate in the Medicaid program and have provided services to enrolled Medicaid beneficiaries. The State or a contractor of the State may conduct the survey.

PROVIDER TAXONOMY CODES

An administrative code set for identifying the provider type and area of specialization for all health care providers. A given provider can have several Provider Taxonomy Codes. This code set is used in the X12 278 Referral Certification and Authorization and the X12 837 Claim transactions, and is maintained by the NUCC.

PROXY

An index of known values that likely approximates an index for which values are unavailable. The proxy is used as a "stand-in" for the unavailable index.

PSYCHIATRIC FACILITY (PARTIAL HOSPITALIZATION)

A facility for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

PSYCHIATRIC FACILITY (PARTIAL HOSPITALIZATION)

Partial hospitalization (location 52) is a program in which a patient attends for several hours during the day (example: 8:30-3:30) the patient is not there on a 24 hours basis.

PSYCHIATRIC RESIDENTIAL TREATMENT CENTER

A facility or distinct part of a facility for psychiatric care that provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.

PUBLIC USE FILE

Non-identifiable data that is within the public domain.

PURCHASE ORDER

A type of payment between two Federal agencies.


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Term Definition
QUALIFIED MEDICARE BENEFICIARY (QMB)

This is a Medicaid program for beneficiaries who need help in paying for Medicare services. The beneficiary must have Medicare Part A and limited income and resources. For those who qualify, the Medicaid program pays Medicare Part A premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare services.

QUALIFYING INDIVIDUALS (1) (QI-1S)

This is a Medicaid program for beneficiaries who need help in paying for Medicare Part B premiums. The beneficiary must have Medicare Part A and limited income and resources and not be otherwise eligible for Medicaid. For those who qualify, the Medicaid program pays full Medicare Part B premiums only.

QUALIFYING INDIVIDUALS (2) (QI-2S)

This is a Medicaid program for beneficiaries who need help in paying for Medicare Part B premiums. The beneficiary must have Medicare Part A and limited income and resources and not be otherwise eligible for Medicaid. For those who qualify, Medicaid pays a percentage of Medicare Part B premiums only.

QUALITY

Quality is how well the health plan keeps its members healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person and getting the best possible results.

QUALITY ASSURANCE

The process of looking at how well a medical service is provided. The process may include formally reviewing health care given to a person, or group of persons, locating the problem, correcting the problem, and then checking to see if what you did worked.

QUALITY IMPROVEMENT ORGANIZATION

Groups of practicing doctors and other health care experts. They are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by: inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private Fee-for Service plans, and ambulatory surgical centers.

QUINQUENNIAL MILITARY SERVICE DETERMINATION AND ADJUSTMENTS

Prior to the Social Security Amendments of 1983, quinquennial determinations (that is, estimates made once every 5 years) were made of the costs arising from the granting of deemed wage credits for military service prior to 1957; annual reimbursements were made from the general fund of the Treasury to the HI trust fund for these costs. The Social Security Amendments of 1983 provided for (1) a lump-sum transfer in 1983 for (a) the costs arising from the pre-1957 wage credits, and (b) amounts equivalent to the HI taxes that would have been paid on the deemed wage credits for military service for 1966 through 1983, inclusive, if such credits had been counted as covered earnings; (2) quinquennial adjustments to the pre-1957 portion of the 1983 lump-sum transfer; (3) general fund transfers equivalent to HI taxes on military deemed wage credits for 1984 and later, to be credited to the fund on July 1 of each year; and (4) adjustments as deemed necessary to any previously transferred amounts representing HI taxes on military deemed wage credits.


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Term Definition
RAILROAD RETIREMENT

A federal insurance program similar to Social Security designed for workers in the railroad industry. The provisions of the Railroad Retirement Act provide for a system of coordination and financial interchange between the Railroad Retirement program and the Social Security program.

RANDOM SAMPLE

A random sample is a group selected for study, which is drawn at random from the universe of cases by a statistically valid method.

REAL-WAGE DIFFERENTIAL

The difference between the percentage increases before rounding in (1) the average annual wage in covered employment, and (2) the average annual CPI.

REASONABLE COST

FIs and carriers use CMS guidelines to determine reasonable costs incurred by individual providers in furnishing covered services to enrollees. Reasonable cost is based on the actual cost of providing such services, including direct and indirect cost of providers and excluding any costs that are unnecessary in the efficient delivery of services covered by the program.

REASONABLE-COST BASIS

The calculation to determine the reasonable cost incurred by individual providers when furnishing covered services to beneficiaries. The reasonable cost is based on the actual cost of providing such services, including direct and indirect costs of providers, and excluding any costs that are unnecessary in the efficient delivery of services covered by a health insurance program.

RECIPIENT

An individual covered by the Medicaid program, however, now referred to as a beneficiary.

RECOUPMENT

The recovery by Medicare of any Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness.

REFERRAL

A written OK from your primary care doctor for you to see a specialist or get certain services. In many Medicare Managed Care Plans, you need to get a referral before you can get care from anyone except your primary care doctor. If you don?t get a referral first, the plan may not pay for your care.

REFERRAL

A plan may restrict certain health care services to an enrollee unless the enrollee receives a referral from a plan-approved caregiver, on paper, referring them to a specific place/person for the service. Generally, a referral is defined as an actual document obtained from a provider in order for the beneficiary to receive additional services.

REFERRAL SERVICES

Means any specialty, inpatient, outpatient or laboratory services that are ordered or arranged, but not furnished directly. Certain situations may exist that should be considered referral services for purposes of determining if a physician/group is at substantial financial risk. For example, an MCO may require a physician group/physician to authorize "retroactive" referrals for emergency care received outside the MCO's network. If the physician group/physician's payment from the MCO can be affected by the utilization of emergency care, such as a bonus if emergency referrals are low, then these emergency services are considered referral services and need to be included in the calculation of substantial financial risk. Also, if a physician group contracts with an individual physician or another group to provide services that the initial group cannot provide itself, any services referred to the contracted physician group/physician should be considered referral services.

REGENSTRIEF INSTITUTE

A research foundation for improving health care by optimizing the capture, analysis, content, and delivery of health care information. Regenstrief maintains the LOINC coding system that is being considered for use as part of the HIPAA claim attachments standard.

REGIONAL HOME HEALTH INTERMEDIARY (RHHI)

A private company that contracts with Medicare to pay home health bills and check on the quality of home health care.

REGIONAL OFFICE

CMS has 10 Ros that work closely together with Medicare contractors in their assigned geographical areas on a day-to-day basis. Four of these Ros monitor Network contractor performance, negotiate contractor budgets, distribute administrative monies to contractors, work with contractors when corrective actions are needed, and provide a variety of other liaison services to the contractors in their respective regions.

REHABILITATION

Rehabilitative services are ordered by your doctor to help you recover from an illness or injury. These services are given by nurses and physical, occupational, and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.

REHABILITATION (AS DISTINGUISHED FROM VOCATIONAL REHABILITATION)

A restorative process through which an individual with ESRD develops and maintains self-sufficient functioning consistent with his/her capability.

REJECT STATUS

The encounter data did not pass the "front-end" edit process. M+CO needs to correct the data and resubmit.

RENAL TRANSPLANT CENTER

A hospital unit that is approved to furnish transplantation and other medical and surgical specialty services directly for the care of ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement.

REOPENING

An action taken, after all appeal rights are exhausted, to re-examine or question the correctness of a determination, a decision, or cost report otherwise final.

REPORT CARD

Is a way to check up on the quality of care delivered by health plans. Report cards provide information on how well a health plan treats its members, keeps them healthy, and gives access to needed care. Report cards can be published by States, private health organizations, consumer groups, or health plans.

REQUESTOR

An entity who formally requests access to CMS data.

RERELEASE

When a requestor formally requests permission to rerelease CMS data that has been formatted into statistical or aggregated information by the recipient. CMS is responsible for reviewing the files/reports to ensure that they contain no data elements or combination of data elements that could allow for the deduction of the identity of the Medicare beneficiary or a physician and that the level of cell size aggregation meets the stated requirement.

RESEARCH DATA ASSISTANCE CENTER

A CMS contractor that provides free assistance to academic and non-profit research interested in using Medicare and Medicaid data for research.

RESEARCH PROTOCOL

A document that outlines a strong research design, which clearly states the objectives, background, methods and the significance of the study being proposed.

RESERVE DAYS

(See Lifetime Reserve Days.)

RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY

A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.

RESIDUAL FACTORS

Factors other than price, including volume of services, intensity of services, and age/sex changes.

RESOURCE-BASED RELATIVE VALUE SCALE

A scale of national uniform relative values for all physicians' services. The relative value of each service must be the sum of relative value units representing physicians' work, practice expenses net of malpractice expenses, and the cost of professional liability insurance.

RESPITE CARE

Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program so that the usual caregiver can rest or take some time off.

RESTRAINTS

Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident?s body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body. Chemical restraints are any drug used for discipline or convenience and not required to treat medical symptoms.

REUSE

Reuse of CMS data occurs when a requestor, from the same or different organization requests permission to use CMS data already obtained for a prior approved project.

REVENUE

The recognition of income earned and the use of appropriated capital from the rendering of services in the current period.

REVENUE CODE

Payment codes for services or items in FL 42 of the UB-92 found in Medicare and/or NUBC (National Uniform Billing Committee) manuals (42X, 43X, etc.)

REVIEW OF CLAIMS

Using information on a claim or other information requested to support the services billed, to make a determination.

RIGHTS OF INDIVIDUALS
  • Receive notice of information practices;
  • See and copy own records;
  • Request corrections; Obtain accounting of disclosures;
  • Request restrictions and confidential communications;
  • File complaints
RISK ADJUSTMENT

The way that payments to health plans are changed to take into account a person's health status.

RISK-BASED HEALTH MAINTENANCE ORGANIZATION/COMPETITIVE MEDICAL PLAN

A type of managed care organization. After any applicable deductible or co-payment, all of an enrollee/member's medical care costs are paid for in return for a monthly premium. However, due to the "lock-in" provision, all of the enrollee/member's services (except for out-of-area emergency services) must be arranged for by the risk-HMO. Should the Medicare enrollee/member choose to obtain service not arranged for by the plan, he/she will be liable for the costs. Neither the HMO nor the Medicare program will pay for services from providers that are not part of the HMO's health care system/network.

ROUTINE USE

The purposes identifiable data can be collected and the authority to release identifiable data.

RURAL HEALTH CLINIC

An outpatient facility that is primarily engaged in furnishing physicians' and other medical and health services and that meets other requirements designated to ensure the health and safety of individuals served by the clinic. The clinic must be located in a medically under-served area that is not urbanized as defined by the U.S. Bureau of Census.


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Term Definition
SANCTIONS

Administrative remedies and actions (e.g., exclusion, Civil Monetary Penalties, etc.) available to the OIG to deal with questionable, improper, or abusive behaviors of providers under the Medicare, Medicaid, or any State health programs.

SECOND OPINION

This is when another doctor gives his or her view about what you have and how it should be treated.

SECONDARY PAYER

An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.

SECRETARY

The Secretary of Health and Human Services.

SEER - MEDICARE DATABASE

Consists of a linkage of the clinical data collected by the SEER registries with claims for health services collected by Medicare for its beneficiaries.

SEER PROGRAM

The SEER Program of the National Cancer Institute is the most authoritative source of information on cancer incidence and survival in the United States. For further information go to: http://seer.cancer.gov.

SEGMENT

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

SELF DIALYSIS

Dialysis performed with little or no professional assistance (except in emergency situations) by an ESRD patient who has completed an appropriate course of training, in a dialysis facility or at home.

SELF-EMPLOYMENT

Operation of a trade or business by an individual or by a partnership in which an individual is a member.

SELF-EMPLOYMENT CONTRIBUTION ACT PAYROLL TAX

Medicare's share of SECA is used to fund the HI Trust Fund. In fiscal year 1996, self-employed individuals contributed 2.9 percent of taxable annual income, with no limitation. net income of most self-employed persons to provide for the OASDI and HI programs.

SELF-INSURED

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

SEQUESTER

The reduction of funds to be used for benefits or administrative costs from a federal account based on the requirements specified in the Gramm-Rudman-Hollings Act.

SERVICE

Medical care and items such as medical diagnosis and treatment, drugs and biologicals, supplies, appliances, and equipment, medical social services, and use of hospital RPCH or SNF facilities. (42 CFR 400.202).

SERVICE AREA

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan?s service area.

SERVICE AREA (PRIVATE FEE-FOR-SERVICE)

The area where a Medicare Private Fee-for-Service plan accepts members.

SERVICE CATEGORY DEFINITION

A general description of the types of services provided under the service and/or the characteristics that define the service category.

SHORT RANGE

The next 10 years.

SIDE EFFECT

A problem caused by treatment. For example, medicine you take for high blood pressure may make you feel sleepy. Most treatments have side effects.

SINGLE DRUG PRICER

The SDP is a drug-pricing file containing the allowable price for each drug covered incident to a physician's service, drugs furnished by independent dialysis facilities that are separately billable from the composite rate, and clotting factors to inpatients. The SDP is, in effect, a fee schedule, similar to other CMS fee schedules.

SKILLED CARE

A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.

SKILLED NURSING CARE

A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).

SKILLED NURSING FACILITY

A facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

SKILLED NURSING FACILITY (SNF)

A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.

SKILLED NURSING FACILITY CARE

This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all of your care needs in the facility, including assistance with activities of daily living.

SMALL HEALTH PLAN

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

SMI PREMIUM

Monthly premium paid by those individuals who have enrolled in the voluntary SMI program.

SNF COINSURANCE

For the 21st through 100th day of extended care services in a benefit period, a daily amount for which the beneficiary is responsible, equal to one-eighth of the inpatient hospital deductible.

SOCIAL HEALTH MAINTENANCE ORGANIZATION (SHMO)

A special type of health plan that provides the full range of Medicare benefits offered by standard Medicare HMOs, plus other services that include the following: prescription drug and chronic care benefits, respite care, and short-term nursing home care; homemaker, personal care services, and medical transportation; eyeglasses, hearing aids, and dental benefits.

SOCIAL SECURITY ACT

Public Law 74-271, enacted on August 14, 1935, with subsequent amendments. The Social Security Act consists of 20 titles, four of which have been repealed. The HI and SMI programs are authorized by Title XVIII of the Social Security Act.

SOCIAL SECURITY ADMINISTRATION

The Federal agency that, among other things, determines initial entitlement to and eligibility for Medicare benefits.

SPECIAL ELECTION PERIOD

A set time that a beneficiary can change health plans or return to the Original Medicare Plan, such as: you move outside the service area, your Medicare+Choice organization violates its contract with you, the organization does not renew its contract with CMS, or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP). (See Election Periods; Enrollment; Special Enrollment Period (SEP).)

SPECIAL ENROLLMENT PERIOD

A set time when you can sign up for Medicare Part B if you didn?t take Medicare Part B during the Initial Enrollment Period, because your or your spouse were working and had group health plan coverage through the employer or union. You can sign up at anytime you are covered under the group plan based on current employment status. The last eight months of the Special Enrollment Period starts the month after the employment ends or the group health coverage ends, whichever comes first.

SPECIAL PUBLIC-DEBT OBLIGATION

Securities of the U.S. Government issued exclusively to the OASI, DI, HI, and SMI trust funds and other federal trust funds. Section 1841(a) of the Social Security Act provides that the public-debt obligations issued for purchase by the SMI trust fund shall have maturities fixed with due regard for the needs of the funds. The usual practice in the past has been to spread the holdings of special issues, as of every June 30, so that the amounts maturing in each of the next 15 years are approximately equal. Special public-debt obligations are redeemable at par at any time.

SPECIALIST

A doctor who treats only certain parts of the body, certain health problems, or certain age groups. For example, some doctors treat only heart problems.

SPECIALTY CONTRACTOR

A Medicare contractor that performs a limited Medicare function, such as coordination of benefits, statistical analysis, etc.

SPECIALTY PLAN

A type of Medicare Advantage Plan that provides more focused health care for some people. These plans give you all your Medicare health care as well as more focused care to manage a disease or condition such as congestive heart failure, diabetes, or End-Stage Renal Disease.

SPECIFIED DISEASE INSURANCE

This kind of insurance pays benefits for only a single disease, such as cancer, or for a group of diseases. Specified Disease Insurance doesn?t fill gaps in your Medicare coverage.

SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES (SLMB)

A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.

SPEECH-LANGUAGE THERAPY

Treatment to regain and strengthen speech skills.

SPELL OF ILLNESS

A period of consecutive days, beginning with the first day on which a beneficiary is furnished inpatient hospital or extended care services, and ending with the close of the first period of 60 consecutive days thereafter in which the beneficiary is in neither a hospital nor a skilled nursing facility.

STAFF ASSISTED DIALYSIS

Dialysis performed by the staff of the renal dialysis center or facility.

STANDARD CLAIMS PROCESSING SYSTEM

Certain computer systems currently used by carriers and FIs to process Medicare claims. For physician and lab claims, the system is Electronic Data Systems (EDS); for facility and other Part A provider claims, the system is the Fiscal Intermediary Standard System (FISS), formerly known as the Florida Shared System (FSS); and for supplier claims, the system is the Viable Information Processing System (VIPS).

STANDARD TRANSACTION

Under HIPAA, this is a transaction that complies with the applicable HIPAA standard.

STATE CERTIFICATION

Inspections of Medicare provider facilities to ensure compliance with Federal health, safety, and program standards.

STATE CHILDREN'S HEALTH INSURANCE PROGRAM

Free or low-cost health insurance is available now in your state for uninsured children under age 19. State Children?s Health Insurance Programs help reach uninsured children whose families earn too much to qualify for Medicaid, but not enough to get private coverage. Information on your state?s program is available through Insure Kids Now at 1-877-KIDS NOW (1-877-543-7669). You can also look at www.insurekidsnow.gov on the web for more information.

STATE HEALTH INSURANCE ASSISTANCE PROGRAM

A State program that gets money from the Federal Government to give free local health insurance counseling to people with Medicare.

STATE INSURANCE DEPARTMENT

A state agency that regulates insurance and can provide information about Medigap policies and any insurance-related problem.

STATE LAW

A constitution, statue, regulation, rule, common law, or any other State action having the force and effect of law.

STATE LICENSURE AGENCY

A State agency that has the authority to terminate, sanction, or prosecute fraudulent providers under State law.

STATE MEDICAL ASSISTANCE OFFICE

A State agency that is in charge of the State?s Medicaid program and can give information about programs to help pay medical bills for people with low incomes. Also provides help with prescription drug coverage.

STATE OR LOCAL PUBLIC HEALTH CLINIC

A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.

STATE SURVEY

Under 1864 of the Act, CMS has entered into agreements with agencies of State governments, typically the agency that licenses health facilities within the State Health Departments, to conduct surveys of Medicare participating providers and suppliers for purposes of determining compliance with Medicare requirements for participation in the Medicare program.

STATE SURVEY AGENCY

Agency that inspects dialysis facilities and makes sure that Medicare standards are met.

STATE UNIFORM BILLING COMMITTEE

A state-specific affiliate of the NUBC.

STATUS LOCATION

An indicator on a claim record describing the queue where the claim is currently situated and the action that needs to be performed on the claim.

STOCHASTIC MODEL

An analysis involving a random variable. For example, a stochastic model may include a frequency distribution for one assumption. From the frequency distribution, possible outcomes for the assumption are selected randomly for use in an illustration.

STRATEGIC NATIONAL IMPLEMENTATION PROCESS

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

SUBSIDIZED SENIOR HOUSING

A type of program, available through the Federal Department of Housing and Urban Development and some States, to help people with low or moderate incomes pay for housing.

SUBSTANTIAL FINANCIAL RISK

Means an incentive arrangement that places the physician or physician group at risk for amounts beyond the risk threshold, if the risk is based on the use or costs of referral services. The risk threshold is 25%. However, if the patient panel is greater than 25,000 patients, then the physician group is not considered to be at substantial financial risk because the risk is spread over the large number of patients. Stop loss and beneficiary surveys would not be required.

SUMMARIZED COST RATE

The ratio of the present value of expenditures to the present value of the taxable payroll for the years in a given period. In this context, the expenditures are on an incurred basis and exclude costs for those uninsured persons for whom payments are reimbursed from the general fund of the Treasury, and for voluntary enrollees, who pay a premium in order to be enrolled. The summarized cost rate includes the cost of reaching and maintaining a "target" trust fund level, known as a contingency fund ratio. Because a trust fund level of about 1 year's expenditures is considered to be an adequate reserve for unforeseen contingencies, the targeted contingency fund ratio used in determining summarized cost rates is 100 percent of annual expenditures. Accordingly, the summarized cost rate is equal to the ratio of (1) the sum of the present value of the outgo during the period, plus the present value of the targeted ending trust fund level, plus the beginning trust fund level, to (2) the present value of the taxable payroll during the period.

SUMMARIZED INCOME RATE

The ratio of (1) the present value of the tax revenues incurred during a given period (from both payroll taxes and taxation of OASDI benefits), to (2) the present value of the taxable payroll for the years in the period.

SUPPLEMENTAL EDIT SOFTWARE

A system, outside the Standard Claims Processing System, which allows further automation of claim reviews. It may be designed using the logic, or "expertise" of a medical professional. Appendix P, PSC's Supplemental Edit Software.

SUPPLEMENTARY MEDICAL INSURANCE

The Medicare program that pays for a portion of the costs of physicians' services, outpatient hospital services, and other related medical and health services for voluntarily insured aged and disabled individuals. Also known as Part B.

SUPPLIER

Generally, any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.

SURVEY AND CERTIFICATION PROCESS

The activity conducted by State survey agencies or other CMS agents under the direction of CMS and within the scope of applicable regulations and operating instructions and under the provisions of 1864 of the Act whereby surveyors determine compliance or noncompliance of Medicare providers and suppliers with applicable Medicare requirements for participation. The survey and certification process for each provider and supplier is outlined in detail in the State Operations and Regional Office Manuals published by CMS.

SUSPENSION OF PAYMENTS

The withholding of payment by an FI or carrier from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment exists.

SUSTAINABLE GROWTH RATE

A system for establishing goals for the rate of growth in expenditures for physicians' services.

SYNTAX

The rules and conventions that one needs to know or follow in order to validly record information, or interpret previously recorded information, for a specific purpose. Thus, a syntax is a grammar. Such rules and conventions may be either explicit or implicit. In X12 transactions, the data-element separators, the sub-element separators, the segment terminators, the segment identifiers, the loops, the loop identifiers (when present), the repetition factors, etc., are all aspects of the X12 syntax. When explicit, such syntactical elements tend to be the structural, or format-related, data elements that are not required when a direct data entry architecture is used. Ultimately, though, there is not a perfectly clear division between the syntactical elements and the business data content.

SYSTEM NOTICE

A document published in the Federal Register notifying the public of a new or revised System of Records.

SYSTEM OF RECORDS

A collection of records from which an agency retrieves information by reference to an individual identifier.

SYSTEMATIC

Pursuing a defined objective(s) in a planned, step by step manner.


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Term Definition
TAX AND DONATIONS

State programs under which funds collected by the State through certain health care related taxes and provider-related donations were used to effectively increase the amount of Federal Medicaid reimbursement without a comparable increase in State Medicaid funding or provider reimbursement levels.

TAX RATE

The percentage of taxable earnings, up to the maximum tax base, that is paid for the HI tax. Currently, the percentages are 1.45 for employees and employers, each. The self-employed pay 2.9 percent.

TAXABLE EARNINGS

Taxable wages and/or self-employment income under the prevailing annual maximum taxable limit.

TAXABLE PAYROLL

A weighted average of taxable wages and taxable self-employment income. When multiplied by the combined employee-employer tax rate, it yields the total amount of taxes incurred by employees, employers, and the self-employed for work during the period.

TAXABLE SELF-EMPLOYMENT INCOME

Net earnings from self-employment-generally above $400 and below the annual maximum taxable amount for a calendar or other taxable year-less any taxable wages in the same taxable year.

TAXABLE WAGES

Wages paid for services rendered in covered employment up to the annual maximum taxable amount.

TAXATION OF BENEFITS

Beginning in 1994, up to 85 percent of an individual's or a couple's OASDI benefits is potentially subject to federal income taxation under certain circumstances. The revenue derived from taxation of benefits in excess of 50 percent, up to 85 percent, is allocated to the HI trust fund.

TAXES

See "Payroll taxes."

TECHNOLOGY ASSESSMENT (TA)

Health care TA is a multidisciplinary field of policy analysis. It studies the medical, social, ethical and economic implications of the development, diffusion and use of technologies. In support of NCDs, TA often focuses on the safety and efficacy of technologies. Each NCD includes a comprehensive TA process. For some NCDs, external TAs are requested through the Agency for Health Research and Quality (AHRQ). For a description of the TA process and guiding principles for selecting which topics are refereed for external TA assistance see http://www.cms.hhs.gov/mcac/guidelines.asp.

TELEMEDICINE

Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site.

TERM INSURANCE

A type of insurance that is in force for a specified period of time.

TEST OF LONG-RANGE CLOSE ACTUARIAL BALANCE

Summarized income rates and cost rates are calculated for each of 66 valuation periods within the full 75-year long-range projection period under the intermediate assumptions. The first of these periods consists of the next 10 years. Each succeeding period becomes longer by 1 year, culminating with the period consisting of the next 75 years. The long-range test is met if, for each of the 66 time periods, the actuarial balance is not less than zero or is negative by, at most, a specified percentage of the summarized cost rate for the same time period. The percentage allowed for a negative actuarial balance is 5 percent for the full 75-year period and is reduced uniformly for shorter periods, approaching zero as the duration of the time periods approaches the first 10 years. The criterion for meeting the test is less stringent for the longer periods in recognition of the greater uncertainty associated with estimates for more distant years. This test is applied to trust fund projections made under the intermediate assumptions.

TEST OF SHORT-RANGE FINANCIAL ADEQUACY

The conditions required to meet this test are as follows: (1) If the trust fund ratio for a fund exceeds 100 percent at the beginning of the projection period, then it must be projected to remain at or above 100 percent throughout the 10-year projection period; (2) alternatively, if the fund ratio is initially less than 100 percent, it must be projected to reach a level of at least 100 percent within 5 years (and not be depleted at any time during this period), and then remain at or above 100 percent throughout the rest of the 10-year period. This test is applied to trust fund projections made under the intermediate assumptions.

THIRD PARTY ADMINISTRATOR

An entity required to make or responsible for making payment on behalf of a group health plan.

THIRD PARTY ADMINISTRATOR

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

THIRD PARTY USE

A Third Party Use occurs when a third party from another organization is given permission to use data originally obtained from CMS by the original requestor.

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.

TRANSIENT PATIENTS

Patients who receive treatments on an episodic basis and are not part of a facilities regular caseload (i.e. patients who have not been permanently transferred to a facility for ongoing treatments).

TRANSPLANT

The surgical procedure that involves removing a functional organ from either a deceased or living donor and implanting it in a patient needing a functional organ to replace their nonfunctional organ.

TRAUMA CODE DEVELOPMENT

An MSP investigation process triggered by receipt of a Medicare claim with a diagnosis indicating traumatic injury.

TREATMENT

Something done to help with a health problem. For example, medicine and surgery are treatments.

TREATMENT OPTIONS

The choices you have when there is more than one way to treat your health problem.

TRICARE

A health care program for active duty and retired uniformed services members and their families.

TRICARE FOR LIFE (TFL)

Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.

TRUE NEGATIVES

These are eligibles who have not received any services through the managed care plan, as evidenced by the absence of a medical record and any encounter data. True negatives signify potential access problems, and should be investigated by the managed care plan.

TRUST FUND

Separate accounts in the U.S. Treasury, mandated by Congress, whose assets may be used only for a specified purpose. For the SMI trust fund, monies not withdrawn for current benefit payments and administrative expenses are invested in interest-bearing federal securities, as required by law; the interest earned is also deposited in the trust fund.

TRUST FUND RATIO

A short-range measure of the adequacy of the trust fund level; defined as the assets at the beginning of the year expressed as a percentage of the outgo during the year.

TTY

A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who don?t have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.


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Term Definition
UB-82

A uniform institutional claim form developed by the NUBC that was in general use from 1983 - 1993.

UB-92

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

UNASSIGNED CLAIM

A claim submitted for a service or supply by a provider who does not accept assignment.

UNIFORM CLAIM TASK FORCE

An organization that developed the initial HCFA-1500 Professional Claim Form. The maintenance responsibilities were later assumed by the NUCC.

UNIT INPUT INTENSITY ALLOWANCE

The amount added to, or subtracted from, the hospital input price index to yield the PPS update factor.

UNITED NATIONS CENTRE FOR FACILITATION OF PROCEDURES AND PRACTICES FOR ADMINISTRATION, COMMERCE, AND TRANSPORT

An international organization dedicated to the elimination or simplification of procedural barriers to international commerce.

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

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

URGENTLY NEEDED CARE

Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than the Original Medicare Plan. If you are out of your plan's service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care.

UTAH HEALTH INFORMATION NETWORK

A public-private coalition for reducing health care administrative costs through the standardization and electronic exchange of health care data.

UTILIZATION SUMMARY DATA

Data that are aggregated by the capitated managed care entity (e.g. the number of primary care visits provided by the plan during the calendar year).


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Term Definition
VALIDATION

The process by which the integrity and correctness of data are established. Validation processes can occur immediately after a data item is collected or after a complete set of data is collected.

VALUATION PERIOD

A period of years that is considered as a unit for purposes of calculating the status of a trust fund.

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.

VOCATIONAL REHABILITATION

The process of facilitating an individual in the choice of or return to a suitable vocation. When necessary, assisting the patient to obtain training for such a vocation. Vocational rehabilitation can also mean to preparing an individual regardless of age, status (whether U.S. citizen or immigrant) or physical condition (disability other than ESRD) to cope emotionally, psychologically, and physically with changing circumstances in life, including remaining at school or returning to school, work, or work equivalent (homemaker).

VOLUNTARY AGREEMENT

Agreements between CMS and various insurers and employers to exchange Medicare information and group health plan eligibility information for the purpose of coordinating health benefit payments.

VOLUNTARY ENROLLEE

Certain individuals aged 65 or older or disabled, who are not otherwise entitled to Medicare and who opt to obtain coverage under Part A by paying a monthly premium.


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Term Definition
WAITING PERIOD

The time between when you sign up with a Medigap insurance company or Medicare health plan and when the coverage starts.

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.

WITHHOLD

Means a percentage of payment or set dollar amounts that are deducted from the payment to the physician group/physician that may or may not be returned depending on specific predetermined factors.

WORKERS COMPENSATION

Insurance that employers are required to have to cover employees who get sick or injured on the job.

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).

WORLD HEALTH ORGANIZATION

An organization that maintains the International Classification of Diseases (ICD) medical code set.


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Term Definition
X12

An ANSI-accredited group that defines EDI standards for many American industries, including health care insurance. Most of the electronic transaction standards mandated or proposed under HIPAA are X12 standards.

X12 148

The X12 First Report of Injury, Illness, or Incident transaction. This standard could eventually be included in the HIPAA mandate.

X12 270

The X12 Health Care Eligibility & Benefit Inquiry transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 271

The X12 Health Care Eligibility & Benefit Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 274

The X12 Provider Information transaction.

X12 275

The X12 Patient Information transaction. This transaction is expected to be part of the HIPAA claim attachments standard.

X12 276

The X12 Health Care Claims Status Inquiry transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 277

The X12 Health Care Claim Status Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates. This transaction is also expected to be part of the HIPAA claim attachments standard.

X12 278

The X12 Referral Certification and Authorization transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 811

The X12 Consolidated Service Invoice & Statement transaction.

X12 820

The X12 Payment Order & Remittance Advice transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 831

The X12 Application Control Totals transaction.

X12 834

The X12 Benefit Enrollment & Maintenance transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 835

The X12 Health Care Claim Payment & Remittance Advice transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 837

The X12 Health Care Claim or Encounter transaction. This transaction can be used for institutional, professional, dental, or drug claims. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 997

The X12 Functional Acknowledgement transaction.

X12 IHCEBI & IHCEBR

The X12 Interactive Healthcare Eligibility & Benefits Inquiry (IHCEBI) and Response (IHCEBR) transactions. These are being combined and converted to UN/EDIFACT Version 5 syntax.

X12 IHCLME

The X12 Interactive Healthcare Claim transaction.

X12 STANDARD

The term currently used for any X12 standard that has been approved since the most recent release of X12 American National Standards. Since a full set of X12 American National Standards is only released about once every five years, it is the X12 standards that are most likely to be in active use. These standards were previously called Draft Standards for Trial Use.

X12/PRB

The X12 Procedures Review Board.

X12F

A subcommittee of X12 that defines EDI standards for the financial industry. This group maintains the X12 811 [generic] Invoice and the X12 820 [generic] Payment & Remittance Advice transactions, although X12N maintains the associated HIPAA Implementation guides.

X12J

A subcommittee of X12 that reviews X12 work products for compliance with the X12 design rules.

X12N

A subcommittee of X12 that defines EDI standards for the insurance industry, including health care insurance.

X12N/SPTG4

The HIPAA Liaison Special Task Group of the Insurance Subcommittee (N) of X12. This group's responsibilities have been assumed by X12N/TG3/WG3.

X12N/TG1

The Property & Casualty Task Group (TG1) of the Insurance Subcommittee (N) of X12.

X12N/TG2

The Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12.

X12N/TG2/WG1

The Health Care Eligibility Work Group (WG1) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 270 Health Care Eligibility & Benefit Inquiry and the X12 271 Health Care Eligibility & Benefit Response transactions, and is also responsible for maintaining the IHCEBI and IHCEBR transactions.

X12N/TG2/WG10

The Health Care Services Review Work Group (WG10) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 278 Referral Certification and Authorization transaction.

X12N/TG2/WG12

The Interactive Health Care Claims Work Group (WG12) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the IHCLME Interactive Claims transaction.

X12N/TG2/WG15

The Health Care Provider Information Work Group (WG15) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 274 Provider Information transaction.

X12N/TG2/WG19

The Health Care Implementation Coordination Work Group (WG19) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This is now X12N/TG3/WG3.

X12N/TG2/WG2

The Health Care Claims Work Group (WG2) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 837 Health Care Claim or Encounter transaction.

X12N/TG2/WG3

The Health Care Claim Payments Work Group (WG3) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 835 Health Care Claim Payment & Remittance Advice transaction.

X12N/TG2/WG4

The Health Care Enrollments Work Group (WG4) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 834 Benefit Enrollment & Maintenance transaction.

X12N/TG2/WG5

The Health Care Claims Status Work Group (WG5) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 276 Health Care Claims Status Inquiry and the X12 277 Health Care Claim Status Response transactions.

X12N/TG2/WG9

The Health Care Patient Information Work Group (WG9) of the Health Care Task Group (TG2) of the Insurance Subcommittee (N) of X12. This group maintains the X12 275 Patient Information transaction.

X12N/TG3

The Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12. TG3 maintains the X12N Business and Data Models and the HIPAA Data Dictionary. This was formerly X12N/TG2/WG11.

X12N/TG3/WG1

The Property & Casualty Work Group (WG1) of the Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12.

X12N/TG3/WG2

The Healthcare Business & Information Modeling Work Group (WG2) of the Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12.

X12N/TG3/WG3

The HIPAA Implementation Coordination Work Group (WG3) of the Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12. This was formerly X12N/TG2/WG19 and X12N/SPTG4.

X12N/TG3/WG4

The Object-Oriented Modeling and XML Liaison Work Group (WG4) of the Business Transaction Coordination and Modeling Task Group (TG3) of the Insurance Subcommittee (N) of X12.

X12N/TG4

The Implementation Guide Task Group (TG4) of the Insurance Subcommittee (N) of X12. This group supports the development and maintenance of X12 Implementation Guides, including the HIPAA X12 IGs.

X12N/TG8

The Architecture Task Group (TG8) of the Insurance Subcommittee (N) of X12.


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Term Definition
YEAR OF EXHAUSTION

The first year in which a trust fund is unable to pay benefits when due because the assets of the fund are exhausted.


*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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