Glossary

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.

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 For the SMI trust fund, monies not withdrawn for current benefit payments and administrative expenses are invested in interest-bearing federal securities, as required by law; the interest earned is also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.

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.

tester

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.

A uniform institutional claim form developed by the NUBC that was in general use from 1983 - 1993.

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

A claim submitted for a service or supply by a provider who does not accept assignment.

An organization that developed the initial HCFA-1500 Professional Claim Form. The maintenance responsibilities were later assumed by the NUCC.

The amount added to, or subtracted from, the hospital input price index to yield the PPS update factor.

An international organization dedicated to the elimination or simplification of procedural barriers to international commerce.

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

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.

A public-private coalition for reducing health care administrative costs through the standardization and electronic exchange of health care 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).

The process by which the integrity and correctness of data are established. Validation processescan occur immediately after a data item is collected or after a complete set of data is collected.

A period of years that is considered as a unit for purposes of calculating the status of a trust fund.

A vendor of EDI data communications and translation services.

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

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).

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.

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.

The time between when you sign up with a Medigap insurance company or Medicare health plan and when the coverage starts.

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.

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.

Insurance that employers are required to have to cover employees who get sick or injured on the job.

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.

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

An organization that maintains the International Classification of Diseases (ICD) medical code set.

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.