A.1 Glossary of Medicare Terminology
Abuse Improper or excessive use of program benefits or services by providers or consumers. Abuse can occur, intentionally or unintentionally, when services are used which are excessive or unnecessary; which are not the appropriate treatment for the patient's condition; when cheaper treatment would be as effective; or when billing or charging does not conform to requirements. It should be distinguished from fraud, in which deliberate deceit is used by providers or consumers to obtain payment for services which were not actually delivered or received, or to claim program eligibility. Abuse is not necessarily either intentional or illegal.
Accounts Receivable An account set up to collect money from a beneficiary or provider when there has been a Medicare overpayment. Any payments received from the beneficiary or provider will be applied to the AR until it is satisfied.
Accredited Hospital A hospital approved by the Joint Commission on Accreditation of Health Organizations (JCAHO).
Acute Care A level of care that can be rendered only in a hospital.
Acute Disease A disease which is characterized by a single episode of fairly short duration from which the patient returns to his normal or previous state and level of activity. Acute diseases are distinguished from chronic diseases.
Ad Hoc Request A request to provide non-production support. This support may be in the form of one time updates to production files or the creation of specific one-time or as needed output reports.
Adjudicated Claims A claim that has been fully processed though the system, has been determined to be payable or denied, and for which notification via and EMOB or a remittance advice indicating payment or denial has been mailed.
Adjudication Determination of payment allowance on a claim.
Adjustment Bill/Claim A correction bill/claim subsequent to an original bill/claim which was incorrectly processed or which was incomplete and could not be processed.
Administrative Law Judge Hearing official assigned to the Office of Hearings and Appeals. Conducts evidentiary hearings on appeals from Medicare Part A and B determinations.
Admission Entry to a hospital as a patient.
Admitting Physician The physician responsible for admission of a patient to a hospital or other inpatient health facility. Some facilities have all admitting decisions made by a single physician (typically a rotating responsibility) called an admitting physician.
Advance Directives Written documents stating how you want medical decisions made for you if you lose the ability to make decisions for yourself. The two most common advance directives are: Living Wills and Durable Powers of Attorney for Health Care.
Advance Notice When the provider believes that Medicare will not make payment due to a service being "not reasonable and necessary," an advance written notice to the beneficiary can protect the provider from liability.
Affiliated Hospital One which is affiliated in some degree with another health program, usually a medical school
Age Discrimination in Employment Act of 1967 (ADEA) As amended in 1978, ADEA requires employers with 200 or more employees to offer older active employees under age 70 who are eligible for Medicare (and their spouses if they are also under age 70) the same health insurance coverage that is provided to younger employees.
ALJ Hearing The ALJ hearing is a quasi-judicial administrative hearing conducted by a Federal ALJ. It results in a new decision by an independent reviewer.
Allied-Health Personnel Specially trained health workers other than physicians, dentists, podiatrists and nurses. The term has no constant or agreed upon meaning: sometimes meaning all health workers who perform tasks which must otherwise be performed by a physician; and sometimes referring to health workers who do not usually engage in independent practice.
Allowed Amount Either
the amount billed for a medical service or the amount determined payable by
Medicare, whichever is the lesser figure.
Alternative Delivery Systems (ADS) A method of providing a comprehensive health care program to subscribers other than the traditional fee-for-service method (e.g., HMOs, PPOs).
Ambulatory Care Health services which are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients.
Ambulatory Surgery A large, though limited, range of procedures using operative and anesthesia techniques that allow the patient to recuperate at home, rather than in the hospital, immediately following the operation.
Ambulatory Surgical Center (ASC) a distinct entity which operates exclusively to provide outpatient surgical services.
American Association of Retired Persons A service and lobbying group composed of people age 50 and over that has the Medicare program among its concerns. Commonly known as the AARP.
American Hospital Association (AHA) A voluntary association of hospitals organized for the purpose of helping hospitals provide better patient care.
American Medical Association (AMA) A public service organization dedicated to the advancement of science and medicine and betterment of the public health and welfare.
Americans with Disabilities Act A law enacted in 1990 that prohibits discrimination against persons with disabilities in such areas as public accommodations and terms and conditions of employment.
Amount in Controversy The difference between the amount charged the beneficiary less the amount the Medicare carrier allowed, less any remaining Part B Cash Deductible and/or, if applicable, Part B Blood Deductible, less 20 percent of the remainder. To meet the amount in controversy requirement, a beneficiary or provider may combine any series of claims for Part B services as long as the appeal is timely filed for all claims at issue and the claims are properly at the level of the appeal requested.
Ancillary Charge A charge used on institutional claims for any item except hospital and physician fees, such as drug, lab, or X-ray charges.
Ancillary Services Hospital services other than room and board, and professional services. They may include X-ray, drug, laboratory or other services.
Anesthesiologist or Anesthetist A person who administers anesthetics for surgery and diagnostic procedures. An anesthesiologist is always a holder of the M.D. or D.O. degree; an anesthetist may be a nurse-anesthetist or an anesthesia technician.
Appeal Requests Written statements that convey an explicit or implicit request for review of the initial determination, or a dissatisfaction with the most recent determination.
Approved Charge The amount that Medicare has determined is appropriate for payment to a physician for a service, based on his and his colleagues' histories of charge. See Usual, customary, and reasonable reimbursement system.
Assigned Claim A Part B claim for physician or supplier services where the provider agrees to accept the Medicare allowed charge as payment in full.
Assignment Payment for covered services goes directly to the physician.
Assistant-at-surgery A surgeon who gives aid to and supports a primary surgeon during a surgical procedure.
Attending Physician The physician primarily responsible for the care of a beneficiary with respect to a particular illness or injury. Also a doctor with staff privileges at a hospital who treats patients there. Usually applied to physicians on the staff of a teaching hospital who have a role in teaching and supervising interns and residents.
Audio Response Unit (ARU) The computerized telephone answering service which allows a beneficiary or provider to check claim status using a touch tone telephone.
Balance Billing The practice of charging full fees in excess of covered amounts, then billing the patient for that portion of the bill that the payor does not cover.
Balance Billing Limit A Medicare regulation that limits the maximum fee that a non-participating physician may charge a Medicare beneficiary to 115% above the Medicare-approved amount. The physician is prohibited from collecting the difference or balance between his/her regular fee and the balance billing limit.
Beneficiary Term used to identify any individual eligible for Medicare benefits.
Benefit Period For an inpatient hospital/skilled nursing facility (SNF), this is a period of time starting on the first day that a beneficiary is admitted to a qualified inpatient hospital and ending when he/she has not been an inpatient in a hospital or SNF for 60 consecutive days. If a beneficiary is in an SNF, it ends when he/she has not received any skilled nursing care for 60 consecutive days. There is no limit to the number of benefit periods a beneficiary may have. The beneficiary must pay the Part A deductible for each benefit period. This is also known as a spell of illness. For a hospice, a benefit period is two 90-day periods plus a 30-day period, or an indefinite extension if necessary.
Bilateral Multiple Surgery Multiple surgeries performed on two alike parts of the body, such as the left and right hand.
Bilateral Surgery Procedures that are performed on both sides of the body during the same operative session or on the same day.
Bill/Claim `Bill' and `claim' are used interchangeably for Part A and institutional Part B services (i.e., those services billed through fiscal intermediaries). `Claim' is used for Part B physician/supplier billed through carriers. A bill/claim is essentially a request for payment for medical services rendered by a Medicare provider. Claims are generally submitted on standard claim forms (UB-92 or HCFA 1500) or in an approved electronic format (National Standard Format, ANSI X.12, etc.)
Biologicals Drugs produced by extraction from plant or animal tissue, rather than chemical synthesis. Examples: gamma globulin (from horse serum); human growth hormone.
Blood Deductible Deductible equal in cost to the first three pints of whole blood (or packed red blood cells) received by a beneficiary in a calendar year.
Blue Cross The words and identification symbol used by non-profit hospital service corporations approved by the BCBSA.
Blue Cross and Blue Shield Association (BCBSA) A national non-profit corporation which promotes the betterment of public health and security, and obtains wide public acceptance of the principle of voluntary, non-profit prepayment of health services. BCBSA holds all rights to the words and symbols that represent both corporations.
Board Certified Physicians who have successfully taken the examination of a medical specialty board.
Buy-in The process whereby a state Medicaid program pays the monthly premiums for Medicare Part B coverage (SMI) in order to provide its Medicaid recipients who are eligible for Medicare with that coverage. Claims processed for the recipients are called crossover claims.
Carrier A public or private insurance organization under contract with the Federal Government's Health Care Financing Administration to process claims and inquiries from physicians and suppliers of service.
Carrier Advisory Committee (CAC) A formal mechanism for: a) providers in a state to be informed of, and participate in, the development of medical policy in an advisory capacity; b) to discuss and improve administrative policies that are discretionary, and; c) for information exchange between the Medicare carrier, health care professionals and Medicare beneficiaries.
Carriers Responsible for handling Medicare claims for services by physicians, suppliers, and other health care practitioners covered under Part B of the Medicare program.
Case A covered instance of sickness or injury.
Case Management The process by which all health related matters of a case are managed by a physician or nurse or designated components of health care, such as appropriate referral to consultants, specialists, hospitals, ancillary providers and services. Case management is intended to ensure continuity and accessibility of services.
Catastrophic Illness Any unusually expensive or lengthy illness that greatly exceeds an individual's ability to pay.
Categorically Needy Those aged, blind, or disabled individuals or families who meet Medicaid eligibility criteria by qualifying for AFDC, SSI, or an optional State financial supplement.
Certificate of Medical Necessity (CMN) A certificate that documents the medical necessity need of a piece of durable medical equipment, prosthetic and orthotic device or a replacement supply.
Change Request HCFA mechanism used for submitting a request to change, add, or delete functions within the operational Medicare system.
Charges Prices assigned to units of medical service, such as a visit to a physician or a day in a hospital. Charges for services may not be related to the actual costs of providing the services. Further, the methods by which charges are related to costs vary substantially from service to service and institution to institution. Different third-party payers may require use of different methods of determining either charges or costs.
Claim A request for payment for benefits received or services rendered.
Claim Line That portion of a claim form, regardless of submission media, that describes a uniquely identified service, supply, or drug and the units, place, dates, charge, and other information directly related to that service, supply, or drug.
Claims Review The method by which an enrollee's health care service claims are reviewed prior to reimbursement. The purpose is to validate the medical necessity of the provided services and to be sure the cost of the service is not excessive.
Clean Bill/Claim A bill/claim requiring no investigation, development, or correction.
Clinical Laboratory A laboratory where microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, or pathological examinations are performed on materials derived from the human body, to provide information for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition.
Clinical Laboratory Improvement Amendment (CLIA) An amendment which states that all clinical laboratory services that are furnished to Medicare beneficiaries must be performed by a provider who has certification from the CLIA program.
Coinsurance The part of each Medicare approved amount a Medicare beneficiary must pay after they have paid the deductible.
Common Working File (CWF) A query/reply system which determines a beneficiary's deductible and entitlement status.
Community Hospital A non-profit hospital established to serve a specific geographic area.
Comparative Performance Report (CPR) A report to monitor and profile physician's billing patterns within each area or locality and provide comparative data to physicians whose utilization patterns vary significantly from other physicians in the same payment and/or locality.
Competitive Medical Plan An arrangement for prepaid care that is not as restricted as a health maintenance organization is in benefits offered, premium calculation, and the like.
Comprehensive Medical Review (CMR) A group of physicians within a medical group that reviews statistical data to determine which physicians are causing an aberrance within the group.
Concurrent Review Review of a procedure or hospital admission done by a health care professional (usually a nurse) other than the one providing the care.
Conditional Payment Medicare makes payment on third party liability cases so providers and beneficiaries do not have to wait for the case to be settled in the courts for payment. Once the case is settled, Medicare receives reimbursement by the other insurance company.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) This statute contains a provision requiring most employers maintaining group health plans to permit employees, their spouses, and their dependents to elect to continue, on a self-pay basis, group coverage for 18, 24, or 36 months, depending on the qualifying event.
Coordination of Benefits (COB) A process in which insurers cooperate to make sure that they do not, together, pay more than the maximum benefit available from any of them.
Coordination Period Specified period of time when the employer plan is the primary payer to Medicare.
Copayment A specified dollar amount or percentage of the charge identified that is paid by a beneficiary at the time of service to a health care plan, physician, hospital, or other provider of care for covered service provided to the beneficiary.
Cost Sharing The general set of financial arrangements whereby the consumer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of health care services, or both. Cost sharing can also occur when an insured pays a portion of the monthly premium for heath care insurance.
Cost Shifting Charging one group of patients more in order to make up for underpayment by others. Most commonly, charging some privately insured patients more in order to make up for underpayment by Medicaid or Medicare.
Co-Surgery A single surgical procedure which requires the skills of two surgeons of different specialties.
Coverage Period The period during which an individual is entitled to benefits, and the period in which, if applicable, premiums are due.
Covered Services Those services and benefits to which the eligible beneficiary is entitled under the Medicare program.
Crossover Claim A claim for which both Titles XVIII (Medicare) and Title XIX (Medicaid) are potentially liable for payment or qualifying medical services.
Current Procedural Terminology (CPT) A system of terminology and coding developed by the American Medical Association that is used for describing, coding and reporting medical services and procedures
Deductible The amount a beneficiary pays for Medicare approved expenses before Medicare starts to pay.
Denied Claim A claim for services that Medicare determines should not be paid for by the Medicare program, such as services provided to an ineligible beneficiary, services provided by an ineligible provider, or services not billed in a correct manner.
Department of Health and Human Services The federal department charged with the administration of national welfare program. Formed from the old Department of Health, Education, and Welfare when the Department of Education was split off.
Dependent Person (spouse or child) other than the subscriber who is covered in the subscriber's benefit certificate.
Development A request for additional information needed to process a claim or inquiry. An examiner enters an appropriate development code into the system, and the system generates the development letter(s) requesting the desired information.
DHHS Department of Health and Human Services
Diagnosis The determination of the nature of a disease.
Diagnosis Code A numerical classification descriptive of diseases, injuries and causes of death: International Morbidity Code, Manual of the International Statistical Classification of Diseases, injuries and AMA Standard Nomenclature of Disease, etc.
Diagnosis-Related Groups (DRGs) System that reimburses health care providers fixed amounts for all care given in connection with standard diagnostic categories
Diagnostic Service An examination or procedure to which patient is subjected, or which is performed on material derived from the patient, to obtain information to aid in the assessment of a medical condition or the identification of a disease.
Diagnostic Workup The process of testing and checking various hypotheses about possible conditions a patient may have when this cannot be immediately established from symptoms, history, or routine tests.
Dialysis Use of a machine to remove waste products or toxins from the blood to assist or replace kidney function.
Direct Payment Individuals not part of a group insurance plan who purchase their health insurance independently.
Disability Income Insurance A form of insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury or disease.
Discharge Release or dismissal from care
DMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Drug Formulary An alphabetical listing of individual drugs along with their corresponding strengths and prices.
Duplicate Claim A claim or service that is either totally or partially an exact representation of a claim or service previously paid or in process.
Durable Medical Equipment (DME) Medical equipment that can stand repeated use and is appropriate for use in the home, such as wheelchairs, canes, walkers, and oxygen delivery equipment.
Durable Medical Equipment Regional Carrier (DMERC) The Medicare carriers that process claims for durable medical equipment, prosthetics, orthotics, and supplies.
Durable Power of Attorney A delegation of some authority to another, which lasts until revoked.
Edit Validation of data.
Effective Date The date on which the insurance under a policy begins.
ElectronicData Interchange (EDI) EDI - The letters officially stand for Electronic Data Interchange, a rather technical way of saying the completely electronic exchange of information from one computer to another. The transmission of information can be via dial-up (aka modem) or magnetic tape and must be programmed in one of two standard formats; National Standard Format (NSF) or the American National Standards Institute (ANSI) ASC X12N.
Elective Surgery or Procedure A surgery or procedure that, given the patient's diagnosis and condition, can be performed at any convenient time; contrast with urgent procedure, one that must be done very soon, and emergency procedure, one that must be done immediately.
Electronic Media Claims Claims data transmitted via various electronic media, including tapes, diskettes, CPU to CPU, etc. EMC claims are submitted in an approved standard electronic format, such as the National Standard Format (NSF) or an American National Standards Institute (ANSI) format.
Emergency A situation requiring immediate care to prevent death, serious injury, or deformity; contrast with urgent.
Emergency Care Care for patients with severe or life-threatening conditions that require immediate intervention.
Emergency Services Those inpatient or outpatient hospital services which are necessary to prevent the death or serious impairment of the health of the individual, and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible hospital available and equipped to furnish such services.
Employee Retirement Income Security Act of 1974 (ERISA) Primarily enacted to effect pension equality, ERISA also contains provisions to protect the interests of group insurance plan participants and beneficiaries. It requires, among other things, that insurance plans be established pursuant to a written instrument that describes the benefits provided under the plan, names the persons responsible for the operation of the plan, and spells out the arrangements for funding and amending the plan.
Employer Group Health Plan (EGHP) Group health plan provided by a single employer of 20 or more employees or provided by an employee organization associated with that employer
Encounter A record of services provided to a patient for which no fee for service payment is made primarily processed for reporting purposes.
End State Renal Disease (ESRD) That stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.
Enrollment Period Period during which individuals may enroll for insurance benefits. Most contributory group insurance has an annual enrollment period when members of the group may elect to begin contributing and become covered.
EPO Epoiten Alfa Therapeutic Injections
Exclusions Specific conditions or circumstances listed in the policy for which the policy will not provide benefit payments.
Experimental or Investigative Any treatment, procedure, facility, equipment, drug or drug usage, device or supply which is not accepted, standard medical practice by the general medical community or Highmark, or does not have federal or government agency approval.
Experimental Services Those services which Medicare has not proven to be clinically effective (i.e., research or experimental studies).
Explanation of Benefits (EOB) The explanation generated by an insurance that pays BEFORE Medicare pays, i.e., Employer Group Health Plan, workers compensation, etc.
Explanation of Medicare Benefits A statement generated to the beneficiary to explain the action taken on each Medicare claim. Commonly known as the E.O.M.B.
Face Sheet The top document in a patient's hospital chart, which the doctor attests is correct as to conditions and procedures to obtain payment from Medicare under the DRG system.
Fair Hearing This is the second level in the administrative appeals process which generally follows a review determiniation conducted by the Post Payment Review department.
Family Practice/Family Practitioner Delivery of primary heath care to all members of families by a physician trained in general practice plus elements of pediatrics and obstetrics and gynecology; one who delivers such care.
Federal Employee Program (FEP) A medical program designed for federal employees or retirees and their families.
Federal Fiscal Year A 12-month period beginning October 1 and ending September 30 each year.
Federally Qualified HMO HMOs that meet certain federally stipulated provisions aimed at protecting consumers, e.g., providing a broad range of basic health services, assuring financial solvency, and monitoring the quality of care. The qualification process is administered by HCFA.
Fee Disclosure Physicians and caregivers discussing their charges with patients prior to treatment.
Fee Schedule A comprehensive listing of fees used by either a health care plan or the government to reimburse physicians and/or other providers on a fee-for-service basis.
Fee-for-Service Method of charging whereby a physician or other practitioner bills for each encounter or service rendered. This system contrasts with salary, per capita or prepayment systems, where the payment is not changed with the number of services actually used.
Fiscal Intermediary The agent (e.g., Blue Cross) that has contracted with providers of service to process claims for reimbursement under health care coverage. In addition to handling financial matters, it may perform other functions such as providing consultative services or serving as a center for communication with providers and making audits of providers' needs.
Flexibility The ability of a system to be capable of easily accepting changes, modifications, or new technology with minimum disruption.
Focused Medical Review (FMR) A program in which Medicare carriers provide a more targeted medical review of those items, services, and providers that present the greatest risk of inappropriate Medicare Part B program payment.
Formulary A list of selected pharmaceuticals and their appropriate dosages felt to be most useful and cost effective for patient care. See Drug Formulary.
Fraud Intentional misrepresentation by either providers or consumers to obtain services or payment for services. Fraud may include deliberate misrepresentation of need or eligibility; providing false information concerning costs or conditions to obtain reimbursement or certification; or claiming payment for services which were never delivered or received. Fraud is illegal and carries a penalty when proven. See also Abuse
Freedom of Choice Options Arrangements under which members of a health maintenance organization or other prepaid plan can use physicians who are outside the panel of participating doctors, if they wish to do so. Additional payment is usually involved.
Freedom of Information Act (FOIA) Enacted in 1966 in order to establish the presumption that records in the possession of agencies and departments of the Executive Branch of the United States Government are accessible to the people; set standards for determining which records must be disclosed and which records can be withheld.
Free-Standing Surgical Center A health care facility staffed by licensed physicians which is designed to handle surgical procedures that do not require overnight hospital care.
General Enrollment Period The time from January 1 to March 31 of each year when anyone eligible for Part B of Medicare can enroll in it.
General Medical/Surgical Floors The areas of a hospital in which patients who do not require special treatment are cared for.
Global Surgery A standard package of preoperative, intraoperative, and postoperative services that are included in the payment for a surgical procedure.
Government Furnished Resource Any resource (equipment, personnel, or other property) supplied by the Federal government for contractor use. Commonly known by the acronym GFR.
Group A body of subscribers eligible for group insurance by virtue of some common identifying attribute, such as common employment by an employer, or membership in a union, association or other organization.
Group Model HMO An HMO that is staffed by the doctors in a group practice, who may or may not have ownership interest or control. An HMO that contracts with a multi-specialty medical group to provide care for HMO members; members are required to receive medical care from a physician within the group unless a referral is made outside the network.
Group Number A numerical identification assigned to a group.
Group Practice A situation in which a group of doctors share facilities and support staff, and often makes an attempt to offer patients of the group a range of specialties.
Group Provider Identification Number A provider identification number assigned to an entity where more than one practitioner is rendering services. This number allows payment to be made under one name and one tax identification number.
HCFA-1500 Uniform claim form approved by HCFA which is required for most professional providers to bill for most non-institutional services.
Health and Human Services (HHS) A department of the federal government which is responsible for the services provided by the office of the Social Security Administration, Health Care Financing Administration and Public Health Services.
Health Care Financing Administration Agency within the US Department of Health and Human Services (HHS) that administers the nation's Medicare program (Tittle XVIII of the Social Security Act).
Health Insurance Claim Number (HIC) The identification number issued by the Social Security Administration to a person covered under Medicare.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Establishes portability, pre-existing condition, nondiscrimination and guaranteed renewal rules for small and large group markets, including self-funded or insured coverage. HIPAA also establishes guaranteed issue rules for the small group market (defined as 2-50 employees), including self-funded coverage. Establishes guaranteed issue, portability and renewability rules for the individual market
Health Maintenance Organization (HMO) A public or private organization which provides, either directly or through arrangements with others, a comprehensive range of health services to enrolled members who live within a specified service area. Payment is based on a predetermined periodic rate, or periodic per capita rate, without regard to the frequency or extent of covered services furnished to any particular member. The HMO must also meet statutory requirements.
Health Plan Any health care organization, insurance company, or health insurance organization that provides covered services on a risk basis to enrollees.
Health Professional Shortage Area (HPSA) An area defined by the Bureau of the Census as having a shortage of health professionals. A HPSA can be urban or rural.
Home Health Agency An agency approved by Medicare for the delivery of home services to Medicare beneficiaries. Known by the acronym HHA.
Home Health Care Care rendered in a patient's residence by employees of a home health agency or other approved providers of home health care.
Homemaker Services Non-medical support services (e.g., food preparation, bathing) given a homebound individual who is unable to perform these tasks himself. Homemaker services are intended to preserve independent living and normal family life for the aged, disabled, sick or convalescent.
Hospice A program which provides care for terminally ill patients and their families, either directly or on a consulting basis with the patient's physician. The whole family is considered the unit of care. Emphasis is on symptom control and support before and after death.
Hospice Care Care provided for beneficiaries who have a terminal illness with a life expectancy of six months or less; these beneficiaries have the option of electing hospice coverage instead of the standard Medicare coverage.
Hospital An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and nonsurgical. In addition, most hospitals provide some outpatient services, particularly emergency care. Hospitals are classified by length of stay (short-term or long-term); as teaching or nonteaching; by major type of service (psychiatric, tuberculosis, general, and specialty, such as maternity, pediatric, or ear, nose and throat); and by control (government, federal, state or local, for-profit and nonprofit). The hospital system is dominated by the short-term, general, nonprofit community hospital.
Hospital Services Those medically necessary services for patients that are generally and customarily proved by acute care general hospitals and prescribed, directed, or authorized by the attending physician.
Hospital-based Physicians Term for doctors who treat patients exclusively or almost exclusively in hospitals and so use the hospital as their office, the place of primary contact with patients. Often the hospital bills for their services and pays them a salary.
Host A site responsible for supplying the intermediaries and carriers with beneficiaries deductible and entitlement status, as well as maintaining all beneficiary and claims history information for each beneficiary assigned to that particular host.
Host Site A Medicare contractor which operates the CWF system and maintains a CSF data base for a specific geographic sector.
House Staff Doctors in training in a hospital, plus hospital-based physicians, who are the primary physicians for patents who do not have personal physicians and assist in the care of those who do.
Hyperalimentation Total nutrition via a tube placed in a vein. Proteins, fats, electrolytes, and carbohydrates are all provided, in contrast to a shorter-term administration of intravenous solutions that contain only electrolytes and sugars. Also called total parenteral nutrition (TPN).
ICD-9 International Classification of Diseases 9th Edition. Coding and terminology for conveying primary and secondary diagnoses on claim forms.
Image Character Recognition (ICR) A system used to capture claim information directly from the HCFA _ 1500 claim form; all information which is captured by the computer is transferred into an electronic file which is then passed to the Medicare claims processing system.
Immunosuppressive Drug A drug given to control the immune system to keep it from damaging a transplanted organ or causing additional damage to normal tissues in an autoimmune disease.
Incident to Physician Services Services that are provided as an integral part of the physician services, may be provided by auxiliary personnel.
Incomplete Claim Denial Return of assigned claim to claimant because essential information such as the ICD-9-CM Code or Unique Physician Identification Number (UPIN) is missing. This action is not appealable. The claimant must resubmit the claim and may not bill the beneficiary until Medicare gives the claimant a decision.
Independent Laboratory A laboratory which is independent both of the attending or consulting physician's office and of the hospital.
Individual Enrollment Period The time, running from three months before one's 65th birthday to three months after, during which one can enroll in Part B of Medicare without a premium increase for delayed enrollment.
Individual Practice Association (IPA) A health maintenance organization that is staffed by physicians in private practice who continue to maintain their own offices and see both HMO and non-HMO patients.
Individual Provider Identification Number An identification number assigned to providers by the carrier; required for any provider, regardless of participation status, who wishes to submit claims to Medicare for reimbursement.
Inpatient A subscriber who occupies a hospital bed while receiving hospital care, including room, board and general nursing care.
Inpatient Hospital Care Care that is rendered in a hospital to someone who has been formally admitted and temporarily lives in the hospital while receiving treatment.
Inquiry A phoned, written, or walk-in request by a beneficiary or provider for the status of bills/claims or general Medicare information other than reimbursement, financial, medical or utilization review, or MSP.
Integrated Delivery Systems (IDS) A health care system that has the ability to deliver all aspects of care including: preventive, ambulatory, inpatient, tertiary care, home health and skilled nursing. In most instances, such systems exist in managed care environments. An IDS must be able to monitor delivery of services with respect to quality and cost. Generally, an IDS also has centralized governance and centralized operational and financial systems.
Intensive Care Unit A part of the hospital in which people whose life support requires constant monitoring, or who require close and constant observation, are cared for.
Intermediary Public or private organization under contract with HCFA to process Part A (inpatient) and Part B (outpatient) institutional claims and inquiries.
Intermediate Care Facility An institution (nursing home) providing health related care and services to individuals who do not require the degree of care provided by a hospital or skilled nursing home, but who, because of their physical or mentation condition, require care and services above the level of room and board. An ICF provides less intensive care than a Skilled Nursing Facility (SNF), and rehabilitation therapies are stressed.
Large Group Health Plan (LGHP) A plan provided by an employer who employs 100 or more persons or a plan belonging to a multi-employer plan where at least one employer has 100 or more full or part time employees.
Length of Stay (LOS) The length of an inpatient's stay in a hospital or other health facility. It is one measure of use of health facilities, reported as an average number of days spent in a facility per admission or discharge.
Licensed Practical Nurse (LPN) A nurse who has practical experience in the provision of nursing care but is not a graduate of a degree program of nursing education.
Limiting Charge Congress-enacted law which limits what a physician may charge Medicare beneficiaries for medical services; every charge on a NONASSIGNED Medicare claim for physician's services is subject to a legal limit called the limiting charge; these physician charges to a Medicare beneficiary may not exceed the maximum of 115% of the Medicare allowed amount for any service or procedure rendered.
Limiting Charge Exception Report (LCER) A report which is sent to providers whom the Medicare carrier has identified as exceeding their limiting charge; designed for informational purposes only.
Limiting Charge Monitoring Report (LCMR) A retrospective review and notice sent to those providers who fail to meet acceptable levels of limiting charge compliance; these noncompliance notices are mailed after completion of a monthly review of the Limiting Charge Exception Report files.
Living Will A document executed prior to or early in the course of an illness, expressing one's wishes in regard to medical treatment if one becomes unable to direct the course of it personally. May or may not be explicitly permitted by the laws of the individual states.
Long-Term Care Services required by persons who are chronically ill, aged, disabled, or retarded, in an institution or at home, on a long-term basis. The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for the retarded and mental hospitals.
Long-Term Disability A significant period of disability, generally ranging from six months to life.
Major Medical Insurance Health insurance to finance the expense of major illness and injury. Characterized by large benefit maximums, the insurance, above an initial deductible, reimburses the major part of charges for hospital, doctor, private nurses, medical appliances, prescribed out-of-hospital treatment, drugs and medicines. The insured person as co-insurer pays the remainder.
Managed Care The coordination of health care services for members through a network of health care providers, quality and utilization monitoring and other cost containment methods, i.e., preauthorization for hospital care. Managed care is provided through HMOs, PPOs, EPOs, POS and managed indemnity plans, etc. Collectively known as MCOs.
Maximum Actual Allowable Charge The amount nonparticipating physicians are actually allowed to charge Medicare beneficiaries for their services.
MCM Medicare Carriers Manual
Medicaid A medical coverage program jointly funded by both the states and the federal governments; for those residents who qualify because of an annual income which falls below the state or nationally indicated poverty level.
Medical Group Practice Provision of health care services by a group of at least three licensed physicians engaged in a formally organized and legally recognized entity sharing equipment, facilities, common records and personnel involved in both patient care and business management.
Medical Necessity A decision made by appropriate professional staff after a service is provided as to the medical need for that service. The state of being thought to be required by the prevailing medical consensus. What is medically necessary in one period or one area may not be so in another.
Medical Necessity Determination A formal judgment, usually made for purposes of insurance payment, that a treatment was or was not medically necessary.
Medical Review The function of determining the medical necessity and appropriateness of care provided to a Medicare patient.
Medical Savings Account (MSA) A provision of HIPAA in which employees of small businesses with 50 or fewer employees, the self-employed and uninsured would be permitted to make tax deductible contributions (or have an employer make contributions) to medical savings accounts where the funds would be used to pay for unreimbursed medical expenses. MSAs are exempt from taxation. State MSA laws may provide additional tax breaks.
Medical Technician An individual with training that allows him or her to carry out some of the functions of holders of the M.D. or D.O. degrees, especially in emergency situations outside of hospitals and during transport to hospitals, when limited by intense life support services must be provided.
Medically Needy Eligible for Medicaid, not because of absolute lack of income, but because income, less accumulated medical bills, is below state income limits for the Medicaid program.
Medically Not Necessary This term does not mean inappropriate medical care, but only that the provider and insurance company disagree on the patient's need for a particular medical service, that the insurance company usually does not pay for the particular service in question, that the treatment is too new and innovative, or that there is another reason for nonpayment.
Medicare A Federal health insurance program which provides coverage for people 65 and older, for certain disabled people, and for some people with End Stage Renal Disease (ESRD); enacted into law in 1965 by Congress through Title XVIII of the Federal Social Security Act, and managed by the Health Care Financing Administration (HCFA), a branch of the Department of Health and Human Services (DHHS). q Hospital Insurance _ Part A - Coverage which helps pay for inpatient hospital care, some inpatient care in a skilled nursing facility, some home healthcare, and hospice care. Hospitals submit their claims to their Part A intermediaries; usually premium free with a deductible per benefits period. q Medical Insurance _ Part B - Coverage which helps pay for medical and surgical services by physicians, as well as certain other health benefits such as ambulance transportation, durable medical equipment, outpatient hospital services, and independent laboratory services; designated to complement the coverage provided by Part A of the program; beneficiaries pay a premium and are responsible for an annual deductible.
Medicare — Public Law 89-97 Provides hospital and physician expenses for eligible Social Security beneficiaries. Part A — That portion of the federal Medicare program that helps pay for inpatient hospital care and certain follow-up care. Part B — That portion of the federal Medicare program that helps pay for doctors' services and other medical services and items. HCFA — Health Care Financing Administration. HCFA 1490S Form — Patient's request for Medicare payment. Replaces HCFA 1490 for beneficiaries. HCFA 1500A Form — Uniform health insurance claim form. Request for Payment form. This form replaces HCFA 1490 effective 09/01/81. Delaware will use 1500 and the District of Columbia will use 1500DC. HCFA 1554 Form — Hospital component fees. HCFA 1660 Form — Statement of person requesting payment on behalf of an estate. Used to establish a "representative payee."
Medicare Approved Charge The amount that Medicare has determined to be the maximum amount allowable for any given service. There is a 5% differential between the approved charges for services rendered by participating providers and the approved charges for services rendered by nonparticipating providers. The participating approved amount is 5% higher.
Medicare Contractors Private firms, generally insurance companies, that contract with HCFA to handle the day-to-day Medicare administration (e.g., pay bills). About three-fourths of the contractors are Blue Cross and Blue Shield Plans.
Medicare Entitlement When an individual becomes entitled to Medicare, he/she receives a Health Insurance Claim card which shows his/her name, sex, Medicare number, and the effective dates of entitlement to hospital (Part A) benefits and medical (Part B) benefits. Entitlement begins the first day of the month of the individuals birth and ends the last day of the month, with the exception of death
Medicare Fraud and Investigations Unit (MFIU) A unit that controls and develops potential Medicare fraud and abuse cases.
Medicare Insured Group (MIG) An experimental approach to providing care to Medicare beneficiaries in which a traditional provider of retiree benefits, such as a corporation or union welfare plan, takes over responsibility for all care to those 65 or over in return for a set payment from Medicare.
Medicare Medical Policy Bulletins (MMPB) Guidelines that address medical issues, including diagnostic and therapeutic procedures, medical supplies, and equipment, and scope of license limitations for our health service doctors.
Medicare Secondary Payor (MSP) Program designed for those beneficiaries who have primary insurance in the private sector. These beneficiaries are then eligible for secondary benefits under Medicare.
Medicare SELECT A type of Medigap insurance policy that only pays full supplemental benefits if covered services are provided by selected providers (except in emergencies). The insurance companies that sell Medicare SELECT are responsible for establishing the network of providers. Medicare SELECT policies conform to all Medigap regulations and must have the approval of the insurance department in the states where they are sold.
Medigap A Medicare supplemental insurance policy or other health benefit plan offered by a private company to those entitled to Medicare benefits. These plans provide reimbursement for Medicare approved charges not reimbursable because of the applicability of deductible, co-insurance amounts or other Medicare imposed limitations.
Medigap Policy A health insurance policy designed to supplement Medicare coverage, including coinsurance and deductible amounts, and services not covered by Medicare (e.g., prescription drugs).
Method I An arrangement for ESRD treatment where the beneficiary receives the home dialysis equipment, supplies, and support services directly from the dialysis facility with which he is associated.
Method II An arrangement for ESRD treatment where the beneficiary makes his own arrangements with an independent supplier for home dialysis equipment , supplies, and support services.
Modifiers Two digit codes that indicate services or procedures have been altered by some specific circumstance. Modifiers do not change the definition of the reported procedure codes.
Multispecialty Group A group of doctors who represent various medical specialties and who work together in a group practice.
Network Model HMO An HMO that contracts with two or more independent group practices to provide health services. This type may include a few solo practices, but is primarily organized around groups.
New and Material Evidence Evidence which was not considered when the previous determination or decision was made and which shows facts not available and that may result in a conclusion different from that reached in the determination or decision. Thus, the submittal of any additional evidence is not a basis for reopening. The information must be "new," i.e., not readily available or known to exist at the time of the initial determination or decision.
Noncovered Services Services which Medicare does not pay for, but the patient does. For instance, Medicare does not pay for most self-administerable prescription drugs or immunization (except for pneumococcal, influenza, hepatitis B vaccinations, or immunizations required because of an injury or immediate risk of infections). Other examples of service not covered by Medicare are: routine physical examinations, routine health screenings, such as serum cholesterol screening, hearing test, diabetes screening, thyroid function screening, etc.
Non-participating Provider A provider who has not signed an agreement with Highmark to agree to abide by the Regulations of the Corporation.
Nonprofit Voluntary Hospitals Entities organized to provide hospital services on a nonprofit or nongovernment basis, generally with alleged oversight from the community they serve via self-perpetuating boards of trustees; classic American hospitals.
Nuclear Medicine The branch of medicine concerned with the use of radioactive chemicals, as opposed to electromagnetic radiation, for therapy and diagnosis; overlaps with radiology and radiation therapy.
Nurse Practitioner A registered nurse (R.N.) who has taken additional training and is certified to handle some of the functions of a holder of the M.D. or D.O. degree.
Nursing Facility An inpatient facility offering long-term nursing care services.
OBRA Omnibus Budget Reconciliation Act of 1986, 1989, 1990 or 1993.
Office of Management and Budget (OMB) The agency of the executive branch of government which prepares the budget the President submits to Congress each year and supervises spending by government agencies during the year.
Office of the Inspector General (OIG) Government office that is responsible for monitoring and investigating abuse and fraud.
Omnibus Budget Reconciliation Act of 1990 (OBRA) A legislative act passed by Congress which replaced the reasonable charge mechanism of actual, customary, and prevailing charges with a Resource Based Relative Value Scale fee schedule beginning in 1992, with the transition period lasting until 1996.
Open Enrollment A period of time in which eligible subscribers may elect to enroll in, or transfer between, available programs providing health care coverage.
Operating Room A portion of a hospital, or other facility, specially equipped for surgery.
Ophthalmologist A holder of the M.D. or D.O. degree who specializes in treatment of diseases of the eye with drugs and surgery. May or may not prescribe corrective lenses.
Ordering Physician The physician that orders a service or diagnostic test.
Outcomes Management A clinical outcome is the result of medical or surgical intervention or non-intervention. It is thought that through a data base of outcomes experience, caregivers will know better which treatment modalities result in consistently better outcomes for patients. Outcomes management may lead to the development of clinical protocols.
Outliers Cases that fall outside the statistical norms of the DRG system, either in total cost or in days of hospitalization required. Medicare makes additional payments for outliers if the peer review organization approves.
Out-of-Area Care Care that is given to a member of an HMO when the member is outside of the service area for that HMO. This is an issue largely because federal laws for HMO certification require definition of a service area.
Out-of-Pocket Limit An amount no more than which an insured individual is required to pay, after which his or her insurance policy pays all costs for the services it covers, regardless of other provisions.
Outpatient Having to do with a person, or treatment given to that person, when he or she is not admitted to the hospital. Examples include: Outpatient prescription drugs - Drugs that can be given outside of the hospital. Outpatient surgery - Surgery performed without admission to a hospital, even though the surgery may be performed in the hospital.
Outpatient Care Hospital services and supplies furnished in a hospital outpatient department or emergency room and billed by a hospital in connection with the care of a patient who is not a registered bed patient. Treatment at a hospital, or in a setting outside a hospital, that does not require admission or temporary residence at the hospital.
Over-the-Counter Drug (OTC Drug) A drug which is advertised and sold directly to the public without a prescription (e.g., aspirin).
PAR (Participating Provider) Providers who participate with Highmark and agree to accept our allowance as payment in full for covered services.
Participating An eligible provider or supplier who has entered into an agreement to accept assignment for all services rendered to Medicare patients, and to accept the Medicare approved amount as payment in full for all services rendered; a participating provider or supplier may not ordinarily collect from the beneficiary more than the applicable deductible and coinsurance for covered services.
Participating Physician Agreement An agreement a doctor signs with HCFA to accept assignment on all Medicare claims and to follow certain procedures; renewed annually.
Participating Physician or Supplier A Medicare provider who has signed an agreement on all claims for Medicare beneficiaries. The provider agrees to accept assignment on all Medicare claims in return for certain incentives.
Pathologist A doctor specializing in examining tissues removed from the body and in performing autopsies.
Patient A person under treatment or care, as by a provider or in a hospital.
Patient Eligibility Requirements entitling individuals to Medicare benefits.
Peer Review A review by members of the profession `peers' regarding the quality of care provided a patient, including documentation of care (medical audit), diagnostic steps used, conclusions reached, therapy given, appropriateness of utilization (utilization review), and reasonableness of charges claimed.
Peer Review Organization (PRO) An organization of practicing doctors and other health care professionals who are paid by the federal government to review the care given to Medicare patients.
Performance Standards Standards an individual provider is expected to meet, especially with respect to quality of care.
Periodic Interim Payments Payments made to institutional providers on a regular basis (usually every two weeks) to help maintain their cash flow rather than having payments be made on a bill flow basis. The cumulative payments for the year are adjusted at the end of the year based on provider cost reports. Known as PIPs.
Permanently and Totally Disabled A term under the Social Security Act, applying to those persons who meet the definition of disability in the act and qualify for Social Security payments and Medicare on that basis.
Physiatrist A doctor who specializes in giving and prescribing physical therapy, primarily for rehabilitation.
Physician A doctor of medicine or osteopathy (including osteopathic practitioner) legally authorized to practice in the state in which the services are performed. For certain purposes, dentists, optometrists, podiatrists, and chiropractors are defined as `physicians.'
Physician Extenders Individuals who are trained to do a part of what a holder of the M.D. or D.O. degree can do. They include nurse practitioners, physicians' assistants, and medical technicians. They are used heavily in HMOs.
Physician Payment Reform (PPR) Provision enacted with the passing of the Omnibus Budget Reconciliation Act of 1989, where Congress provided for major changes in the manner which payment for services of physicians was determined under Medicare.
Physician Profile Statistical comparisons of physician practice patterns regarding such factors as the number of visits, referrals and laboratory tests. The statistics are used to develop norms for identifying the most and least efficient providers.
Physician's Services Professional services performed by physicians for a patient including diagnosis, therapy, surgery, consultation, and home, office, and institutional calls.
Physicians' Assistant An individual trained to carry out some of the functions of holders of the M.D. or D.O. degree, usually with more training than a nurse practitioner or a medical technician.
Place of Service Where a service was performed; e.g., hospital, inpatient, hospital outpatient, doctor's office, etc.
Plan of Care The medical treatment plan established by the treating physician.
PMS Pennsylvania Medical Society.
POA Pennsylvania Optometric Association.
Podiatrist A holder of the degree of Doctor of Podiatric Medicine (D.P.M.), concerned with treatment of diseases of the feet.
Point-of-Service Plan Also known as open-ended HMO, the POS plans encourage, but do not require, members to choose a primary care physician. The primary care physician acts as a gatekeeper when making referrals.
POMA Pennsylvania Osteopathic Medical Association.
Portability Term denoting applications that can be easily be moved from one computer system to another.
Power of Attorney A legal document giving a person the power to act as the representative of the other in certain situations, which can be defined in the power of attorney document.
PPA Pennsylvania Podiatry Association.
Practice Parameters Strategies for patient management, developed to assist physicians in clinical decision making. Practice parameters may also be referred to as practice options, practice guidelines, practice policies, or practice standards.
Practice Patterns Statistically detectable tendencies for individual doctors, or groups of them, to treat certain conditions in a certain way.
Preadmission Certification Review of the need for proposed inpatient service(s) prior to time of admission to an institution.
Preauthorization A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed. See Prior Authorization.
Precertification The process of screening certain surgical or medical procedures and inpatient hospital stays to ensure that the treatment plan is medically necessary.
Preferred Provider Organization (PPO) An arrangement in which patients are `locked in' to a group of providers, usually by restrictions on payment for services provided by those not in the group of providers, in return for discounts or expanded services. A wide variety exists; some resemble traditional insurance plans, and some resemble HMOs.
Prepaid Plan A health plan for which premiums are paid on a prospective basis, irrespective of the use of services.
Prepayment Review Claims reviewed systematically or suspended for review prior to final adjudication.
Preventive Medicine Care which has the aim of preventing disease or its consequences. It includes programs aimed at warding off illnesses (e.g., immunizations), early detection of disease and inhibiting further deterioration of the body, including the promotion of health through altering behavior, especially by health education. Preventive medicine also deals with improving the healthfulness of our environment and our relations with it.
Primary Care The point when the patient first seeks assistance from the medical care system and the care of the simpler and more common illnesses. The primary care provider usually also assumes ongoing responsibility for the patient in both health maintenance and therapy of illness.
Primary Care Physician Physicians who, by training, preference, or necessity, practice a very broad range of medical services for persons not in need of highly specialized medical services. Usually cited as including general practitioners, family practitioners, general internists, pediatricians, and gynecologists who take care of both their patients' gynecological and general medical needs.
Primary Diagnosis The chief medical reason for an encounter with a health care provider or admission to a hospital.
Primary Payer Insurance which pays first.
Primary Payer or Primary Carrier Denotes the insurer obligated to pay losses prior to any liability of other, secondary insurers.
Prior Authorization Authorization granted to a provider to render specified services to an eligible beneficiary. See Preauthorization.
Privacy Act of 1974 Act which regulates federal government agency record keeping and disclosure practices, allowing most individuals to seek access to federal agency records about themselves, and requiring that the personal information in agency files be accurate, complete, relevant, and timely.
Private Duty Nursing Care given by a nurse who is hired to care for one individual exclusively in a hospital or nursing home and is paid directly by the individual or his or her family.
Private Room In a hospital or nursing home, a room occupied by only one person, as opposed to a standard two-person room or ward.
Procedure A manipulation of the body to give a treatment or perform a test; more broadly, any distinct service a doctor renders to a patient. All distinct physician services have `procedure codes' in various payment schemes.
Professional Component (PC) The component of a procedure that involves an act or interpretation to be performed by a provider, such as the interpretation of an x-ray. The mechanical act of taking the x-ray itself is called a technical component. The physician work portion of diagnostic tests
Professional Liability Obligation of providers or their professional liability insurers to pay for damages resulting from the acts of omission or commission in treating patients. The term is sometimes preferred by providers to medical malpractice because it does not necessarily imply negligence.
Professional Standards Review Organization (PSRO) A physician-sponsored organization charged with comprehensive and ongoing review of services. The purpose of this review is to determine whether services are: medically necessary; provided in accordance with professional criteria, norms and standards; and in the case of institutional services, rendered in an appropriate setting.
Prognosis A medical prediction of the course or probable outcome of an illness or condition.
Prolonged Physician Services Physician services involving direct (face-to-face) patient contact beyond that of the usual service.
Proprietary Hospital A hospital operated for the purpose of making a profit for its owners. Proprietary hospitals may be owned by physicians for the care of their own and others' patients. There is also a growing number of investor-owned hospitals, usually operated by a parent corporation which may operate a chain of such hospitals.
Prospective Payment Payment made before a service is rendered, and accepted as payment in full by the provider; the opposite of fee-for-service payment.
Prospective Payment System A Medicare payment system for most short-stay, acute care hospitals whereby the hospital is paid a predetermined amount for each Medicare stay based on the DRG of that stay. Also known as PPS.
Protocol A written plan for caring for a particular condition, intended as a guideline to physicians, and usually adopted by a medical institution such as a clinic, hospital, or HMO.
Provider Term used to identify physicians or nonphysician practitioners who bill Medicare for covered services.
Public Health The science dealing with the protection and improvement of community health. Immunizations, sanitation, preventive medicine, quarantine and other disease control activities, occupational health and safety programs, assurance of air, water and food healthfulness, health education, and epidemiology are recognized public health activities.
Pulmonary Specialist A doctor specializing in lung diseases.
Qualified Medicare Beneficiary (QMB) A Medicare beneficiary who qualifies for financial assistance based upon income and resources. Federal law requires state Medicaid programs pay Medicare costs such as deductibles, copayments, and Part B premiums for those who qualify. Information on the QMB program is available from any state Welfare office.
Quality Assurance (QA) Activities and programs intended to assure the quality of care in a defined medical setting. Such programs include peer or utilization review components to identify and remedy deficiencies in quality. The program must have a mechanism for assessing its effectiveness and may measure care against preestablished standards. In the context of a claims processing system, QA assesses the accuracy and timeliness in the processing of claims versus standards established by the Medicare contractor or HCFA.
Quality Assurance/Continuous Improvement A formal set of activities to continually review and positively affect the quality of clinical and administrative services provided, including quality assessment and corrective actions to remedy and deficiencies identified in the quality of direct patient, administrative and support services.
Quality Control Managerial tool which allows management to determine the quality of work performed.
Quarter of Coverage One-fourth of a calendar year during which a person earns enough, in employment covered by Social Security, to have the quarter counted toward the number needed (usually forty) to ensure entitlement to Social Security and Medicare.
Query (Medicare) Communications between a carrier and the Social Security Administration, determining eligibility and deductible information on Medicare recipients
Radiologist A physician specializing in supervision and interpretation of diagnostic X-rays and a variety pf other medical imaging studies, such as CT, MRI, Ultrasound, etc.
Radiotherapy Treatment for cancer and some other conditions using electromagnetic radiation of several varieties.
Reasonable and Customary Charge R&C charge refers to the maximum amount an insurer will reimburse for medical care expenses covered under group health insurance plans.
Rebundling The process of grouping together procedures that have been fragmented by a billing provider.
Recipient An individual eligible for medical assistance in accordance with the Medicaid program.
Recovery Room A place in a hospital where patients are brought after surgery for close observation until they are ready to be taken to their floors or special care units.
Referring Physician The physician that refers a patient for a service or supply.
Registered Nurse (R.N.) Generally, the highest trained of nurses; licensed by a state to provide general nursing services after passing a qualifying examination; may or may not hold collegiate degrees.
Regulation The intervention of government in the market to control entry into or change the behavior of participants in that marketplace through specification of rules for the participants.
Rehabilitation a) restoration of a disabled person to a meaningful occupation, b) a provision in some disability policies that provides for continuation of benefits or other financial assistance while a disabled insured is retraining or attempting to resume productive employment.
Relative Value Scale or Schedule (RVS) A coded listing of physician or other professional services using units which indicate the relative value of the various services they perform, taking into account the time, skill and cost required for each service. Appropriate conversion factors are used to translate the units into dollar fees for each service.
Remittance Advice A statement mailed to a provider detailing charges pending, paid, denied, or returned. Explanation codes are included for those denied or returned for correction.
Representative Payee A person or organization that is responsible for handling an individual's finances when the individual is unable to do so for himself because of mental or physical inabilities.
Resident A doctor taking postgraduate training in a hospital, often working towards certification in a specialty area. Much of the training involves the care of patients under the supervision of more experienced physicians, both those based in the hospital and those who admit patients there.
Resource Based Relative Value Scale A scale which assigns values to procedures in relation to one another; used to establish the Medicare Fee Schedule.
Retrospective Payment Payment to a provider after care is given; fee-for-service payment.
Review The first formal level of appeal following the initial processing of a Part B claim. It is a second look at the claim and supporting documentation by a different employee.
Revised Determination or Decision A revised determination or decision is one in which: q The end result is changed (e.g., a service previously found to be not covered is now found to be covered or the reasonable charge allowed for the service is determined to be incorrect); or q The end result is not changed, but a party might be disadvantaged by the revision (e.g., a request for payment on an assigned claim previously disallowed because the services were not medically necessary and therefore subject to the waiver of liability provisions, is now to be disallowed on a basis that precludes consideration of waiver of liability).
Risk The chance or possibility of loss.
Risk Pooling The fundamental idea behind insurance. A large number of people with a lower probability of high-cost events share the cost, reducing their individual risks to the amount of the insurance premium rather than the full cost of the event, such as an accident or illness; the fundamental concept of insurance.
Satellites A group of intermediaries and carriers who process claims within a specific geographic area, submitting them to their CWF host for pre-payment validation and authorization.
Secondary Diagnosis A condition that exists in addition to the one that is the chief reason for an encounter with a health care provider or admission to a hospital.
Sector A geographic area defined for CWF processing purposes, consisting of one host contractor and its respective satellite contractors.
Service A potentially covered benefit of the Medicare program, performed by a provider for a beneficiary, which is adjudicated separately for other services, usually indicated by a procedure code.
Service Area The geographical region in which an HMO or other prepaid health care plan has agreed to provide services.
Shared System A claims processing system (Part A or Part B) used by more than one fiscal intermediary or carrier. There are two types of shared system arrangements: shared maintenance, where only the system is shared; and shared processing, where both the system and the data center facilities that it runs in are shared.
Sheltered Care Care that is primarily nonmedical. Residents of sheltered or custodial care facilities do not require constant attention from nurses and aides, but need assistance with one or more daily activities or no longer want to be bothered with keeping up a house. The social needs of residents are met in a secure environment free of as many anxieties as possible. Also called custodial care.
Site of Service Differential Payment for some services that are routinely furnished in physicians' offices are reduced when such services are furnished in the following hospital settings: Outpatient Hospital; Emergency Room-Hospital; Comprehensive Outpatient Rehabilitation Facility; ESRD Treatment Facility; and effective for 1994 dates of service, the following settings: Inpatient Hospital; Inpatient Psychiatric Facility; and Comprehensive Inpatient Rehabilitation Facility.
Skilled Nursing Facilities (SNF) An institution licensed under state law and certified by Medicare to provide skilled nursing and rehabilitative services. An institution that offers nursing services similar to those given in a hospital, to aid recuperation of those who are seriously ill. Distinguished from intermediate care and custodial care, which may meet some minor medical needs but are intended primarily to support elderly and disabled individuals in the task of daily living.
Social HMO Experimental programs that try to provide for the medial and social needs of the elderly and disabled in one, prepaid package. These have not been too successful due to higher than anticipated costs.
Social Security Administration (SSA) The part of the Department of Health and Human Services that operates the various programs funded under the Social Security Act and determines eligibility for Medicare.
Social Security Number (SSN) A unique number assigned to each individual by the Social Security Administration for tax benefits and purposes. Also used as a unique personal identifier by many other government programs and private enterprises.
Social Security Office Local offices of the SSA, found throughout the country, which take applications for Social Security and Medicare and handle processing of Medicare requests for reconsiderations and appeals.
Special Care Units Portions of a hospital organized and staffed to take care of one kind of (usually serious) problem; e.g., cardiac care unit, intensive care unit, burn unit.
Specialist A physician who has elected to practice, and usually has special training in, some branch of medicine other than primary care, such as surgery, or an exclusive focus in one area of primary care, such as allergy, gastroenterology, ear-nose-and-throat care, and so on. Especially in urban areas, specialists are expected to have certification from specialty societies or boards that they have had adequate training in the specialty.
Specificity The ability of a medical test to identify a specific diagnosis or condition; contrast with sensitivity.
Specified Low-Income Medicare Beneficiary (SLMB) A Medicare beneficiary who is not eligible for the Qualified Medicare Beneficiary program but may still be eligible for financial assistance. The SLMB program is designed for beneficiaries whose income is slightly higher than the national poverty level, but not more than 10% higher. The SLMB program pays the monthly Part B premium; however, it does not cover the deductible, copayments, or services not covered by Medicare.
SSA Social Security Administration
Staff Model HMO An HMO staffed by doctors who are its employees and are not in individual or group practice.
Stop-Loss Provision An amount no more than which an insured individual is required to pay, after which his or her insurance policy pays all costs for the services it covers, regardless of other provisions.
Summary Voucher Voucher sent to health care professionals with an explanation notifying them of actions taken on assigned claims. The voucher provides the provider with a record of services rendered and the manner in which the claim was processed and paid.
Supplemental Security Income (SSI) A program that provides small stipends to the elderly, blind, and disabled who for one reason or another are not eligible for other, more generous welfare programs.
Supplier A non-institution, non-physician provider of medical supplies such as durable medical equipment, orthotics/prosthetics, ambulances, portable X-ray, and therapists.
Supplies Items furnished by the physician in the course of diagnosis and treatment, such as gauze, ointments, bandages, oxygen, etc.
Surgical Care Center A facility which serves outpatients requiring surgical treatment but not requiring hospitalization as inpatients. Also known as ambulatory surgery.
Surgical Schedule A list of dollar allowances which are payable for various types of surgery, based upon the severity of the procedure.
Suspended Claim A claim that requires further action before it becomes a paid or denied claim.
Swing Bed Facility Rural hospitals with fewer than 100 beds that furnish covered nursing home services to Medicare beneficiaries. The hospital can `swing' its beds between hospital and SNF levels of care on an as-needed basis, if it has obtained swing bed approval from HCFA.
Swing Beds Hospital beds approved by Medicare for use as hospital or skilled nursing facility beds, depending upon demand.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) TEFRA was enacted to prevent discrimination against elderly employees with regard to health insurance. It amended the Social Security Act to make Medicare secondary to employer group health plans for active employees and spouses aged 65 through 69. TEFRA also amended ADEA to require employers to offer employees and dependents aged 65 through 69 the same coverage available to younger employees
Team Surgery A single surgical procedure which requires the skills of more than two surgeons of different specialties, working together to carry out various portions of a complicated surgical procedure.
Technical Component (TC) Typically involves a mechanical act, such as taking an x-ray or an EKG or performing a test on a specimen. The interpretation of the test is called the professional component.
TEFRA Tax Equity and Fiscal Responsibility Act of 1982.
Telephone Device for the Deaf (TDD) A special piece of equipment used by an individual with a hearing impairment to improve hearing capabilities and therefore communications with others.
Tertiary Care Services provided by specialized providers (e.g., neurologists, neurosurgeons, thoracic surgeons, intensive care units). Such services frequently require sophisticated technological and support facilities.
Third Party Liability Other insurance resources that must be utilized by a Medicaid recipient before Medicaid benefits are available.
Third-Party Payer Any organization that pays or insures health or medical expenses on behalf of beneficiaries or recipients (e.g., Blue Cross and Blue Shield Plans, commercial insurance companies, Medicare, and Medicaid). The individual or employer generally pays a premium for such coverage in all private and some public programs. The organization then pays bills on the patient's behalf; such payments are called third-party payments and are distinguished by the separation between the individual receiving the service (the first party), the individual or institution providing it (the second party) and the organization paying for it (the third party).
Title XIX The title of the Social Security Act which contains the principal legislative authority for the Medicaid program, and therefore a common name for the program.
Title XVIII The title of the Social Security Act which contains the principal legislative authority for the Medicare program, and therefore a common name for the program.
Transaction An interchange of information, electronic or otherwise.
Type of Contract A classification of enrollment usually determined by the marital status of the applicant; e.g., single, two-person and family.
UB-92 Uniform billing claim which is required for providers to bill for general hospital inpatient and outpatient services under Medicare Part A. The earlier version of this claim was the UB-82.
Unbundling The practice of charging separately for several services or components of a service.
Unfavorable Determination A determination or decision is "unfavorable" if, for initial decisions, it is a complete denial of coverage/payment, or, for subsequent appeals, it fails to advance the interests of the claimant.
Unique Provider Identification Number (UPIN) A six character identifier (one alpha, five numeric) assigned to physicians by the Health Care Financing Administration.
Urgent Care The diagnosis and treatment of medical conditions that are serious or acute but pose no immediate threat to life and health, but which require medical attention within 24 hours.
Usual, Customary, and Reasonable Reimbursement System A means of determining payments to doctors based on statistical profiles of their, and their colleagues', history of charges.
Utilization The patterns of use of a service or type of service within a specified time period.
Utilization Rate The frequency of usage as related to exposures.
Utilization Review A mechanism used by some insurers and employers that evaluates health care on the basis of appropriateness, necessity, and quality. For hospital review, it can include preadmission certification, concurrent review with discharge planning, and retrospective review.
Utilization Review Committee (URC) A group of doctors in a hospital who review lengths of hospital stays and treatments to make sure that they are medically necessary.
Voucher Messages Messages which appear on provider summary vouchers. These messages describe any payment action taken.
Waiver of Liability A legal removal of an individual's responsibility to pay for a treatment in an instance where Medicare or Medicaid does not pay for it.
Waiver of Liability Provision A provision which states that if the provider informed the beneficiary in writing before the item or service was furnished that Medicare is likely to deny payment for the item or service rendered as "not reasonable and necessary," and obtained his or her agreement to pay, the provider's liability is waived and payment is made to the provider.
Workers' Compensation Insurance against liability to pay benefits for injuries incurred by employees in the course of or arising out of their employment.
Working Aged Employed individuals aged 65 or over and individuals aged 65 or over with employed spouses of any age.
AAO Associate Administrator for Operations
AAP Associate Administrator for Policy
AARP American Assoc. of Retired Persons
ACER Annual Contractor Evaluation Report
ACF2 Access Control Facility
ACPS Advanced Claims Processing System
ADP Automated Data Processor (Processing)
ADR Additional Development Request
AGPAM American Guild of Patient Accounts Managers
AHA American Hospital Association
ALJ Administrative Law Judge
AMA American Medical Association
ANSI American National Standards Institute
APP Application Portability Profile
APS Adjudication Payment System
AQRP Audit Quality Review Program
ARU Audio Response Unit
ASC Ambulatory Surgical Center (Code)
AUF Automatic Update Facility
AWAS Automated Work Administration System
BCBS Blue Cross and Blue Shield
BCBSA Blue Cross and Blue Shield Association
BCBSAZ Blue Cross and Blue Shield of Arizona
BCBSDE Blue Cross and Blue Shield of Delaware
BDF Bulk Data Facility
BDL Benefit Dental Letter
BDMS Bureau of Data Mgmt. and Strategy
BEA Budget Expense Account Unit
BHI Bureau of Health Insurance
BIS Benefit Integrity System
BMACS Part B Medicare Automated Claims Sections
BPO Bureau of Program Operations
C/SPS Cost/Scheduling Performance System
CABS Carrier Access Billing System
CAFM Contractor Administration Budget and Financial Management
CAI Computer Aided Instruction
CAMS Customer Account Mgmt. System
CASE Computer Assisted Software Engineering
CASR Contractor Audit and Settlement Report
CBR CASE Based Reasoning
CBSS Customer Billing Services System
CBT Computer Based Training
CCTV Closed Circuit Television
CDRTS COMDISCO Disaster Recovery
CES Cost Estimating System
CET Continuing Education and Training
CI Configuration Identification
CICS Customer Information Control System
CIP Continuous Improvement Process
CM Configuration Management
CMHC Community Mental Health Clinic
CMN Certificate of Medical Necessity
CMP Configuration Management Plan
CMSS Customer Marketing Services System
CO Contracting Officer
COMPAS COMDISCO Plan Automation System
CORF Comprehensive Outpatient Rehabilitation Facility
COTR Contracting Officers Technical Representative
COTS Commercial Off-the-Shelf
CPA Certified Public Accountant
CPEP Contractor Performance Evaluation Program
CPI Consumer Price Index
CPM Critical Path Method
CPT Claim Processing Timeliness
CPT4 Current Procedure Terminology, 4th Edition
CPU Central Processor Unit
CRB Change Review Board
CRNA Certified Registered Nurse Anesthetists
CROWD Contractor Reporting of Operational and Workload Data
CRT Cathode Ray Tube
CSSR Communication System Segment Replacement
CSTP Carrier Systems Testing Program
CTAPE Cassette Tapes
CTR Contingency Plan Report
CUI Customer User Interface
CWF Common Working File
CWFM Common Working File Maintenance
DAP Data Administration Plan
DASD Direct Access Storage Device
DBMS Data Base Management System
DCN Document Control Number
DCP Department of Carrier Procedures
DDE Direct Data Entry
DDL Data Definition Language
DEC Digital Equipment Corporation
DFD Data Flow Diagram
DME Durable Medical Equipment
DOSD Division of Operational System Development
DPM Deputy Program Manager
DPP Division of Provider Procedures
DRG Diagnosis Related Group
DSCN Data Services Centers and Network
DSMS Development and Support Management System
DSP Design Specification Package
EBCBS Empire Blue Cross Blue Shield
ECR Electronic Cost Report
EDI Electronic Data Interchange
EFT Electronic Funds Transfer
EGHP Employer Group Health Plan
EKMS Electronic Key Management System
EMC Electronic Media Claims
EOMB Explanation of Medicare Benefits
ERA Electronic Remittance Advice
ERD Entity Relationship Diagram
ERN Electronic Remittance Notice
ESRD End Stage Renal Disease
FAR Federal Acquisition Regulation(s)
FEP Front End Processor
FI Fiscal Intermediary
FID Fraud Investigation Data Base
FIPS Federal Information Processing Standards
FIRMR Federal Information Resources Management Regulations
FMR Focused Medical Review
FPLOE Fixed Price Level of Effort
FQHC Federally Qualified Health Center
FSS Florida Shared System
FTS Fraud Tracking System
GAMSS General American Medicare Standard System
GFR Government Furnished Resources
GOSIP Government Open Systems Interconnection Profile
GTEMS GTE Medicare System
GUI Graphical User Interface(s)
HCFA Health Care Financing Administration
HCHDC Highmark Inc. Camp Hill Data Center
HCRIS Hospital Cost Report Info System
HDC HCFA Data Center
HFMA Healthcare Financial Management
HFS Health Financial
HHA Home Health Agency
HHS Health and Human Services
HIC Health Insurance Claim
HIS Health Information System
HISDG HCFA Information Systems Development Guide
HMO Health Maintenance Organization
HPBSS HCFA Part B Standard System
IBC Independence Blue Cross
IBPR Intermediary Benefit Payment Report
ICAM Integrated Computer Aided Manufacturing
ICD Interface Control Document
ICD-9-CM International Classification of Diseases, 9th Edition, Clinical Modification
IDCAMS IDC Access Method Services An IBM Utility
IER Intermediary Expenditure Report
IIN IBM Information Network
IPC Information Processing Center(s)
IR Incident Report
IRDS Information Resource Dictionary System
IRM Information Resource Management
IRS/SSA Internal Revenue Service/Social Security Administration
ISTP Intermediary Systems Testing Project
ITS Inspection Tracking System
IV&V Independent Verification and Validation
IVD Interactive Video Disk
JAD Joint Application Design
JCL Job Control Language
KEPRO Keystone Peer Review Organization
LAN Local Area Network
LOE Level of Effort
MBAS Medicare Benefit Accounting System
MBN Medicare Benefit Notice
MCE Medicare Code Editor
MCPS Medicare Part A Standard System
MCS Multi-Carrier System
MDARS Medicare Data Analysis Reporting System
MFIS Medicare Fraud Information Specialist
MIM Medicare Intermediary Manual
MMS Metropolitan Medicare System
MNW Medicare Northwest
MPIER Medicare Physician Identification Eligibility Record
MPIES Medicare Physician Identification Eligibility System
MR Medical Review
MSP Medicare Secondary Payer (Payor)
MTS Medicare Transaction System
MVS Multiple Virtual System
Multiple Virtual Systems/Enterprise Systems
NDM Network Data Mover
NGFR Non Government Furnished Resources
NIF Not in File
NIT Network Information and Technology
NOMCI Notice of Medigap Claim Information
NOS National Operating Services (GTE)
NOBU Notice of Benefit Utilization
NOU Notice of Utilization
NRP Network Resource Planning (tool)
NSEMC National Standard Electronic Media Claims
NSF National Standard Format
NSS National Systems Support
NUBC National Uniform Billing Committee
OCE Outpatient Code Editor
OIG Office of Inspector General
OMB Office of Management and Budget
OOP Object Oriented Programming
OPOP Office of Program Operational Procedures
ORF Outpatient Rehabilitation Facility
OSA Out-of-Service Area
OSF Open Software Foundation
OSI Open System Interconnection
PAR Project Assistance Request
PC Personal Computer
PDL Program Design Language
PDM Personalized Documentation Manager; Parallel Development Manager
PDS Partitioned Data Sets
PEBTAG Provider Electronic Billing Technical Advisory Group
PEI Production Environment Interface
PIP Periodic Interim Payment
PMCS Program Management Control System
PMP Project Management Plan
POSIX Portable Operating System Interface Exchange
PPS Prospective Payment System
PRIMOS Prime Operating System
PRO Peer Review Organization
PRRB Provider Reimbursement Review Board
PRS PRO Payment Review System
PS&R Provider Statistical and Reimbursement Report
PSC Public Service Commission(s)
PSOR Provider Statistical and Overpayment Report
PUC Public Utilities Commission(s)
PW Project Workbench
QA Quality Assurance
RCICS Registry Customer Information Control System
RCP Report of Contractor Performance
RGT Requirements Gathering Techniques
RMAPS Rocky Mounting A Processing System
RMF Resource Management Facility
RMP Resource Management Plan
RMU Resource Management Unit
RO Regional Office
RPC Remote Procedure Call
RRB Railroad Retirement Board
RTS Recovery Tracking System
Small Disadvantage Business
SCLM Source Code Librarian Manager
SCN Strategic Communication Network
SDA System Design Alternatives
SDLC System Dev. (Design) Life Cycle
SDM/S Systems Development Methodology/ Structured
SES System External Specifications
SIS System Internal Specifications
SLIM Software Life Cycle Maintenance
SMF System Measurement Facility
SMI Supplementary Medical Insurance
SMS System Managed Storage
SNF Skilled Nursing Facility
SOW Statement of Work
SPARCS Statewide Planning and Research Cooperative System
SPC Standard Properties Corporation
SPR Standard Paper Remittance
SPIN Supplier Profile Identification Number
SQL System Query Language
SRD Systems Requirements Document
SSA Social Security Administration
SSB HCFA Standard Systems Branch
SSC Shared Services Center
STAR System Tracking for Audit and Reimbursement
TAR Telephone Assistance Request
TMCS Time Management Collection System (GTE)
TPNS TeleProcessing Network Simulator
TQM Total Quality Management
TSO/ISPF TSO Interactive System Productivity Facility
UMS Universal Measured Service
UPIN Unique Physician Identification Number
UPS Uninterruptable Power Supply
UR Utilization Review
VIPS Viable Information Processing Systems
VM/ESA Virtual Machine/Enterprise Systems Architecture
VOS Virtual Operating System
VSAM Virtual Storage Access Method
WAN Wide Area Network
WBS Work Breakdown Structure
WC Workers Compensation
WEDI Workgroup Electronic Data Interchange
WPS Wisconsin Physicians Service