Search Frequenty Asked Questions

A group that promotes the development and improvement of state and national health information systems.

An association of the insurance commissioners of the states and territories.

An association of state Medicaid directors. NASMD is affiliated with the American Public Health Human Services Association (APHSA).

A federal organization within the CDC that collects, analyzes, and distributes health care statistics. The NCHS maintains the ICD-n-CM codes.

An organization that accredits managed care plans, or Health Maintenance Organizations (HMOs). In the future, the NCQA may play a role in certifying these organizations' compliance with the HIPAA A/S requirements. The NCQA also maintains the Health Employer Data and Information Set (HEDIS).

A non-profit organization that accredits and measures the quality of care in Medicare health plans. NCQA does this by using the Health Employer Data and Information Set (HEDIS) data reporting system. (See Health Employer Data and Information Set (HEDIS).)

A Federal advisory body within HHS that advises the Secretary regarding potential changes to the HIPAA standards.

An ANSI-accredited group that maintains a number of standard formats for use by the retail pharmacy industry, some of which have been adopted as HIPAA standards.

Numerous documents support the national coverage determination process. They include tracking sheets to inform the public of the issues under consideration and the status (i.e., Pending, Closed) of the review, information about and results of MCAC meetings, Technology Assessments, and Decision Memoranda that announce CMS's intention to issue an NCD. These documents, along with the compilation of medical and scientific information currently available, any FDA safety and efficacy data, clinical trial information, etc., provide the rationale behind the evidence-based NCDs.

An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision (see LMRP). Prior to an NCD taking effect, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to our claims-processing contractors. That issuance, which includes an effective date and implementation date, is the NCD. If appropriate, the Agency must also change billing and claims processing systems and issue related instructions to allow for payment. The NCD will be published in the Medicare National Coverage Determinations Manual. An NCD becomes effective as of the date listed in the transmittal that announces the manual revision.

A policy developed by CMS that indicates whether and under what circumstances certain services are covered under the Medicare program. It is published in CMS regulations, published in the Federal Register as a final notice, contained in a CMS ruling, or issued as a program instruction.

A medical code set maintained by the Food and Drug Administration that contains codes for drugs that are FDA-approved. The Secretary of HHS adopted this code set as the standard for reporting drugs and biologics on standard transactions.

A system for uniquely identifying all sponsors of health care benefits.

This is a healthcare-specific lane on the Information Superhighway, as described in the National Information Infrastructure (NII) initiative. Conceptually, this includes the HIPAA A/S initiatives.

HCQIP projects developed by a group consisting of representatives of some or all of the following groups: CMS, Public Health Service, Networks, renal provider, and consumer communities. The object is to use statistical analysis to identify better patterns of care and outcomes, and to feed the results of the analysis back into the provider community to improve the quality of care provided to renal Medicare beneficiaries. Each project will have a particular clinical focus.

The national median charge is the exact middle amount of the amounts charged for the same service. This means that half of the hospitals and community mental health centers charged more than this amount and the other half charged less than this amount for the same service.

A system for uniquely identifying all recipients of health care services. This is sometimes referred to as the National Individual Identifier (NII), or as the Healthcare ID.

A system for uniquely identifying all organizations that pay for health care services. Also known as Health Plan ID, or Plan ID.

The database envisioned for use in maintaining a national provider registry.

A system for uniquely identifying all providers of health care services, supplies, and equipment. A term proposed by the Secretary of HHS as the standard identifier for health care providers.

The organization envisioned for assigning National Provider IDs.

The administrative system envisioned for supporting a national provider registry.

Generically, this applies to any nationally standardized data format, but it is often used in a more limited way to designate the Professional EMC NSF, a 320-byte flat file record format used to submit professional claims.

National rates for each 6 home health disciplines based on historical claims data. Used in payment of LUPAs and calculation of outliers.

An organization, chaired and hosted by the American Hospital Association, that maintains the UB-92 hardcopy institutional billing form and the data element specifications for both the hardcopy form and the 192-byte UB-92 flat file EMC format. The NUBC has a formal consultative role under HIPAA for all transactions affecting institutional health care services.

An organization, chaired and hosted by the American Medical Association, that maintains the HCFA-1500 claim form and a set of data element specifications for professional claims submission via the HCFA-1500 claim form, the Professional EMC NSF, and the X12 837. The NUCC also maintains the Provider Taxonomy Codes and has a formal consultative role under HIPAA for all transactions affecting non-dental non-institutional professional health care services.

When the Decision Memorandum is issued, the NCA is considered closed. However, the policy change is not effective until the NCD is issued.

The decision memorandum provides the reasons supporting an NCD and announces CMS's intent to issue an NCD. Prior to any new or modified policy taking effect, CMS must first issue a Manual Transmittal, CMS ruling or Federal Register Notice, giving specific directions to our claims-processing contractors. That manual transmittal, or other issuance, which includes the effective date, is the actual NCD. If appropriate, the Agency must also change billing and claims processing systems and issue related instructions to allow for payment. The NCD will be published in the Medicare National Coverage Determinations Manual. Policy changes become effective as of the date listed in the Manual Transmittal that announces the National Coverage Determinations Manual revision.

An NCA is considered new if CMS has received a coverage request or a current NCD is being edited. The "N" at the end of the tracking number (e.g., CAG-0000N) indicates a new NCA.

A pending NCA is one currently under review. The Decision Memorandum has not yet been issued. The subject may or may not be an existing NCD.

A pending NCA is one currently under review. The Decision Memorandum has not yet been issued. The subject may or may not be an existing NCD.

A formal reconsideration can be requested if the requestor presents documentation that meets either of the following criteria: additional medical material or scientific information that was not considered during the initial review; or arguments that our conclusion materially misinterpreted the existing evidence at the time the NCD was made. The ôRö at the end of the tracking number (e.g, CAG-0000R) indicates a reconsideration. Further reconsiderations are annotated with a number after the ôRö, e.g., R2, R3, etc.

A NCPDP format for use by low-volume dispensers of pharmaceuticals, such as nursing homes. The Secretary of HHS adopted Version 1.0 of this format as a standard transaction.

An NCPDP standard designed for use by high-volume dispensers of pharmaceuticals, such as retail pharmacies. Use of Version 5.1 of this standard has been mandated under HIPAA.

A NCPDP format designed for use by high-volume dispensers of pharmaceuticals, such as retail pharmacies. The Secretary of HHS adopted Version 5.1 of this format as a standard transaction.

When care takers do not give a person they care for the goods or services needed to avoid harm or illness.

A group of doctors, hospitals, pharmacies, and other health care experts hired by a health plan to take care of its members.

No-fault insurance is insurance that pays for health care services resulting from bodily injury or damage to your property regardless of who is at fault for causing the accident.

Wages and wages in kind that were not subject to the HI tax but are deemed as having been. Deemed wage credits exist for the purposes of (1) determining HI program eligibility for individuals who might not be eligible for HI coverage without payment of a premium were it not for the deemed wage credits; and (2) calculating reimbursement due the HI trust fund from the general fund of the Treasury. The first purpose applies in the case of providing coverage to persons during the transitional periods when the HI program began and when it was expanded to cover federal employees; both purposes apply in the cases of military service wage credits (see "Military service wage credits" and "Quinquennial military service determinations and adjustments") and deemed wage credits granted for the internment of persons of Japanese ancestry during World War II.

The service:

• does not meet the requirements of a Medicare benefit category,
• Is statutorily excluded from coverage on ground other than 1862(a)(1), or
• is not reasonable and necessary under 1862 (a)(1).

Assets that are held by an entity but are not available to the entity. These are also amounts that, when collected, cannot be spent by the reporting entity.

A State or local government agency that receives records contained in a
system of records from a Federal agency to be used in a matching program.

Drugs not on a plan-approved list.

A doctor or supplier who does not accept assignment on all Medicare claims. (See Assignment.)

An organization that promotes the advancement and integration of information technology into the health care industry.

A document that describes a subject area for which the Federal Government is considering developing regulations. It may describe the presumably relevant considerations and invite comments from interested parties. These comments can then be used in developing an NPRM or a final regulation.

A notice you get to show what action was taken on a claim. (See Explanation of Medicare Benefits; Medicare Benefits Notice; Medicare Summary Notice.)

The billing notice sent to Medicare beneficiaries who must pay their Medicare premium directly. Notices are sent either monthly or quarterly.

A document that describes and explains regulations that the Federal Government proposes to adopt at some future date, and invites interested parties to submit comments related to them. These comments can then be used in developing a final regulation.

A term used by CMS for a proposed standard identifier for health plans. CMS had previously used the terms PayerID and PlanID for the health plan identifier.

The NUBC EDI Technical Advisory Group, which coordinates issues affecting both the NUBC and the X12 standards.

A nurse who has 2 or more years of advanced training and has passed a special exam. A nurse practitioner often works with a doctor and can do some of the things a doctor does.

A facility which primarily provides to residents skilled nursing care and relate services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health related care services above the level of custodial care to other than mentally retarded individuals.

A residence that provides a room, meals, and help with activities of daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance.

Getting enough of the right foods with vitamins and minerals a body needs to stay healthy. Malnutrition, or the lack of proper nutrition, can be a serious problem for older people.