Search Frequenty Asked Questions

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

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

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

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

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

Your ability to get needed medical care and services.

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

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

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

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

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

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

Having a seal of approval. Being accredited means that a facility or health care organization has met certain quality standards. These standards are set by private, nationally recognized groups that check on the quality of care of health care facilities and organizations.

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

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

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

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

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

A negative actuarial balance.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Administrator of the Centers for Medicare and Medicaid Services.

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

Code indicating patient's diagnosis at admission.

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

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

A notice that a doctor or supplier should give a Medicare beneficiary to sign in the following cases: Your doctor gives you a service that he or she believes that Medicare does not consider medically necessary; and your doctor gives you a service that he or she believes that Medicare will not pay for. If you do not get an ABN to sign before you get the service from your doctor, and Medicare does not pay for it, then you do not have to pay for it. If the doctor does give you an ABN that you sign before you get the service, and Medicare does not pay for it, then you will have to pay your doctor for it. ABN only applies if you are in the Original Medicare Plan. It does not apply if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan. (See Medicare Managed Care Plan; Original Medicare Plan.)

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

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

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

A person who gives you support or protects your rights.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A national voluntary association of certified public accountants.

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

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

Standards developed and approved by organizations accredited by ANSI.

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

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

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

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

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

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

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

An appeal is a special kind of complaint you take if you disagree with any decision about your health care services. For example, you would file an appeal if Medicare doesn't pay or doesn't pay enough for a service you got, you don't get, or an item or service you think you should get. This complaint is made to your Medicare health plan or the Original Medicare Plan. There is usually a special process you must use to make your complaint. (See Appeal Process.)

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

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

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

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

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

In the Original Medicare Plan, this means a doctor agrees to accept Medicare's fee as full payment. If you are in the Original Medicare Plan, it can save you money if your doctor acepts assignment. You still pay your share of the cost of the doctor's visit. (See Actual Charge; Approved Amount; Coinsurance.)

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

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

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

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

See also Hospital assumptions.

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

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

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

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

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

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

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

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