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Glossary

This glossary explains terms found on the cms.hhs.gov web site, but it is not a legal document.

 

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A B C D E F G H I J K L M
 
N O P Q R S T U V W X Y Z

General Glossary

Term Definition
LARGE GROUP HEALTH PLAN

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

LETTER OF REQUEST

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

LETTER OF SUPPORT

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

LIABILITY DETERMINATION

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

LIABILITY INSURANCE

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

LICENSED (LICENSURE)

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

LICENSED BY THE STATE AS A RISK-BEARING ENTITY

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

LIFETIME RESERVE DAYS

Under HI, each beneficiary has 60 lifetime reserve days that he or she may opt to use when regular inpatient hospital benefits are exhausted. The beneficiary pays one-half of the inpatient hospital deductible for each lifetime reserve day used.

LIFETIME RESERVE DAYS (MEDICARE)

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

LIMITING CHARGE

The highest amount of money you can be charged for a covered service by doctors and other health care providers who don't accept assignment. The limit is 15% over Medicare's approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment. (See Approved Amount; Assignment.)

LINE ITEM

Service or item specific detail of claim.

LIVING DONOR KIDNEY TRANSPLANT

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

LMRP ARTICLES

Articles and Frequently Asked Questions (FAQs) that appear on contractor websites address local coverage, coding and medical review related billing issues.

LOCAL CODE(S)

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

LOCAL CODES

A generic term for code values that are defined for a State or other local division or for a specific payer. Commonly used to describe HCPCS Level III Codes.

LOCAL COVERAGE DETERMINATION (LCD)

An LCD, as established by Section 522 of the Benefits Improvement and Protection Act, is a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary). The difference between LMRPs and LCDs is that LCDs consist only of "reasonable and necessary" information, while LMRPs may also contain category or statutory provisions.

The final rule establishing LCDs was published November 11, 2003. Effective December 7, 2003, CMS's contractors will begin issuing LCDs instead of LMRPs. Over the next 2 years (until December 31, 2005) contractors will convert all existing LMRPs into LCDs and articles. Until the conversion is complete, for purposes of a 522 challenge, the term LCD will refer to both 1.) Reasonable and necessary provisions of an LMRP and, 2.) an LCD that contains only reasonable and necessary language. Any non-reasonable and necessary language a contractor wishes to communicate to providers must be done through an article.

LOCAL COVERAGE DETERMINATION (LCD)

An LCD, as established by Section 522 of the Benefits Improvement and Protection Act, is a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary). The difference between LMRPs and LCDs is that LCDs consist only of "reasonable and necessary" information, while LMRPs may also contain category or statutory provisions.

LOCAL MEDICAL REVIEW POLICY (LMRP)

LMRP is an administrative and educational tool to assist providers, physicians and suppliers in submitting correct claims for payment. Local policies outline how contractors will review claims to ensure that they meet Medicare coverage requirements. CMS requires that LMRPs be consistent with national guidance (although they can be more detailed or specific), developed with scientific evidence and clinical practice, and are developed through certain specified federal guidelines.

Contractor Medical Directors develop these policies. Reviewing Local Medical Review Policies assists in understanding why Medicare claims may be paid or denied. For a full description of the process and criteria used in developing LMRPs, refer to Chapter 13 of the Medicare Program Integrity Manual. For information about how to request that the authoring contractor conduct a reconsideration of an LMRP, refer to Chapter 13, Section 11.

LOGICAL OBSERVATION IDENTIFIERS, NAMES AND CODES

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

LONG RANGE

The next 75 years.

LONGER TERM CARE MINIMUM DATA SET

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

LONG-TERM CARE

A "variety" of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilties. Most long-term care is custodial care. Medicare does not pay for this type of care.

LONG-TERM CARE INSURANCE

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

LONG-TERM CARE OMBUDSMAN

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

LOOP

A repeating structure or process.

LOW COST ALTERNATIVE

See "Assumptions."


*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

This glossary explains terms found on the cms.hhs.gov web site, but it is not a legal document.

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Note: If any of the glossary information is inaccurate, please submit a glossary data change request to CMS.
Last Modified on Thursday, September 23, 2004