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.


*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.