Search Frequenty Asked Questions

Administrative remedies and actions (e.g., exclusion, Civil Monetary Penalties, etc.) available to the OIG to deal with questionable, improper, or abusive behaviors of providers under the Medicare, Medicaid, or any State health programs.

The SB Crosswalk document is available from the PBP HELP menu and provides a detailed explanation of how each SB sentence is derived from the PBP variables.

A screen is an area beneath the tab where variables are presented. A tab represents a screen. The variables on the screen are displayed by selecting a tab. A tab may contain one or more sub tabs.

This is when another doctor gives his or her view about what you have and how it should be treated.

An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other health insurance depending on the situation.

The Secretary of Health and Human Services.

Consists of a linkage of the clinical data collected by the SEER registries
with claims for health services collected by Medicare for its
beneficiaries.

The SEER Program of the National Cancer Institute is the most authoritative source of information on cancer incidence and survival in the United States. For further information go to: http://seer.cancer.gov.

Under HIPAA, this is a group of related data elements in a transaction.

Dialysis performed with little or no professional assistance (except in emergency situations) by an ESRD patient who has completed an appropriate course of training, in a dialysis facility or at home.

Operation of a trade or business by an individual or by a partnership in which an individual is a member.

Medicare's share of SECA is used to fund the HI Trust Fund. In fiscal year 1996, self-employed individuals contributed 2.9 percent of taxable annual income, with no limitation. net income of most self-employed persons to provide for the OASDI and HI programs.

An individual or organization that assumes the financial risk of paying for health care.

The reduction of funds to be used for benefits or administrative costs from a federal account based on the requirements specified in the Gramm-Rudman-Hollings Act.

Medical care and items such as medical diagnosis and treatment, drugs and biologicals, supplies, appliances, and equipment, medical social services, and use of hospital RPCH or SNF facilities. (42 CFR 400.202).

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disemroll you if you move out of the plan's service area.

The area where a Medicare Private Fee-for-Service plan accepts members.

A general description of the types of services provided under the service and/or the characteristics that define the service category.

The next 10 years.

A problem caused by treatment. For example, medicine you take for high blood pressure may make you feel sleepy. Most treatments have side effects.

The SDP is a drug-pricing file containing the allowable price for each drug covered incident to a physician’s service, drugs furnished by independent dialysis facilities that are separately billable from the composite rate, and clotting factors to inpatients. The SDP is, in effect, a fee schedule, similar to other CMS fee schedules.

A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.

A level of care that must be given or supervised by Registered Nurses. All of your needs are taken care of with this type of service. Examples of skilled nursing care are: getting intravenous injections, tube feeding, oxygen to help you breathe, and changing sterile dressings on a wound. Any service that could be safely done by an average non-medical person (or one's self) without the supervision of a Registered Nurse is not considered skilled care.

A facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.

Under HIPAA, this is a health plan with annual receipts of $5 million or less.

Monthly premium paid by those individuals who have enrolled in the voluntary SMI program.

For the 21st through 100th day of extended care services in a benefit period, a daily amount for which the beneficiary is responsible, equal to one-eighth of the inpatient hospital deductible.

A special type of health plan that provides the full range of Medicare benefits offered by standard Medicare HMOs, plus other services that include the following: prescription drug and chronic care benefits, respite care, and short-term nursing home care; homemaker, personal care services, and medical transportation; eyeglasses, hearing aids, and dental benefits.

Public Law 74-271, enacted on August 14, 1935, with subsequent amendments. The Social Security Act consists of 20 titles, four of which have been repealed. The HI and SMI programs are authorized by Title XVIII of the Social Security Act.

The Federal agency that, among other things, determines initial entitlement to and eligibility for Medicare benefits.

A set time that a beneficiary can change health plans or return to the Original Medicare Plan, such as: you move outside the service area, your Medicare+Choice organization violates its contract with you, the organization does not renew its contract with CMS, or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP). (See Election Periods; Enrollment; Special Enrollment Period (SEP).)

A set time when you can sign up for Medicare Part B if you did not take Part B during the Initial Enrollment Period, because you or your spouse currently work and have group health plan coverage through the employer or union. You can sign up at any time you are covered under the group plan. If the employment or group health coverage ends, you have 8 months to sign up.The 8-month SEP starts the month after the employment ends or the group health coverage ends, whichever comes first. The Special Enrollment Period is different from the Special Election Period. (See Enrollment; Election Periods; Special Election Period.)

Securities of the U.S. Government issued exclusively to the OASI, DI, HI, and SMI trust funds and other federal trust funds. Section 1841(a) of the Social Security Act provides that the public-debt obligations issued for purchase by the SMI trust fund shall have maturities fixed with due regard for the needs of the funds. The usual practice in the past has been to spread the holdings of special issues, as of every June 30, so that the amounts maturing in each of the next 15 years are approximately equal. Special public-debt obligations are redeemable at par at any time.

A doctor who treats only certain parts of the body, certain health problems, or certain age groups. For example, some doctors treat only heart problems.

A Medicare contractor that performs a limited Medicare function, such as coordination of benefits, statistical analysis, etc.

A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.

A period of consecutive days, beginning with the first day on which a beneficiary is furnished inpatient hospital or extended care services, and ending with the close of the first period of 60 consecutive days thereafter in which the beneficiary is in neither a hospital nor a skilled nursing facility.

Dialysis performed by the staff of the renal dialysis center or facility.

Certain computer systems currently used by carriers and FIs to process Medicare claims. For physician and lab claims, the system is Electronic Data Systems (EDS); for facility and other Part A provider claims, the system is the Fiscal Intermediary Standard System (FISS), formerly known as the Florida Shared System (FSS); and for supplier claims, the system is the Viable Information Processing System (VIPS).

Under HIPAA, this is a transaction that complies with the applicable HIPAA standard.

Inspections of Medicare provider facilities to ensure compliance with Federal health, safety, and program standards.

A state program that gets money from the federal government to give free health insurance counseling and assistance to people with Medicare.

A state agency that regulates insurance and can provide information about Medigap policies and any insurance-related problem.

A constitution, statue, regulation, rule, common law, or any other State action having the force and effect of law.

A State agency that has the authority to terminate, sanction, or prosecute fraudulent providers under State law.

A state agency that is in charge of the State's Medicaid program and can provide information about programs to help pay medical bills for people with low incomes. Also provides help with prescription drug coverage.

A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.

Under §1864 of the Act, CMS has entered into agreements with agencies of State governments, typically the agency that licenses health facilities within the State Health Departments, to conduct surveys of Medicare participating providers and suppliers for purposes of determining compliance with Medicare requirements for participation in the Medicare program.

A state-specific affiliate of the NUBC.

An indicator on a claim record describing the queue where the claim is currently situated and the action that needs to be performed on the claim.

Benefit Offerings are considered step-up benefits if a plan benefit package includes one of the following benefit structures in a particular service category: 1) more than one optional supplemental benefit; 2) both a mandatory and optional benefit; or 3) both an additional and optional benefit. For example, a plan may offer three prescription drug optional supplemental benefits, which offer varying levels of drug coverage; in this case, two of the optional benefit offerings would be considered step-up benefits. Alternatively, a plan may offer prescription drug benefits as either an additional or mandatory benefit and then an optional benefit; in this case, the optional benefit would be considered a step-up benefit.

An analysis involving a random variable. For example, a stochastic model may include a frequency distribution for one assumption. From the frequency distribution, possible outcomes for the assumption are selected randomly for use in an illustration.

A national WEDI effort for helping the health care industry identify and resolve HIPAA implementation issues.

A sub screen is an area beneath the sub tab where variables are presented. A sub tab represents a sub screen. The variables on the sub screen are displayed by selecting a sub tab.

A type of program, available through the Federal Department of Housing and Urban Development and some States, to help people with low or moderate incomes pay for housing.

Means an incentive arrangement that places the physician or physician group at risk for amounts beyond the risk threshold, if the risk is based on the use or costs of referral services. The risk threshold is 25%. However, if the patient panel is greater than 25,000 patients, then the physician group is not considered to be at substantial financial risk because the risk is spread over the large number of patients. Stop loss and beneficiary surveys would not be required.

The ratio of the present value of expenditures to the present value of the taxable payroll for the years in a given period. In this context, the expenditures are on an incurred basis and exclude costs for those uninsured persons for whom payments are reimbursed from the general fund of the Treasury, and for voluntary enrollees, who pay a premium in order to be enrolled. The summarized cost rate includes the cost of reaching and maintaining a "target" trust fund level, known as a contingency fund ratio. Because a trust fund level of about 1 year's expenditures is considered to be an adequate reserve for unforeseen contingencies, the targeted contingency fund ratio used in determining summarized cost rates is 100 percent of annual expenditures. Accordingly, the summarized cost rate is equal to the ratio of (1) the sum of the present value of the outgo during the period, plus the present value of the targeted ending trust fund level, plus the beginning trust fund level, to (2) the present value of the taxable payroll during the period.

The ratio of (1) the present value of the tax revenues incurred during a given period (from both payroll taxes and taxation of OASDI benefits), to (2) the present value of the taxable payroll for the years in the period.

A Super User is the user who defined the plans in HPMS and downloaded from the HPMS Web site.

A system, outside the Standard Claims Processing System, which allows further automation of claim reviews. It may be designed using the logic, or "expertise" of a medical professional. Appendix P, PSC's Supplemental Edit Software.

The Medicare program that pays for a portion of the costs of physicians' services, outpatient hospital services, and other related medical and health services for voluntarily insured aged and disabled individuals. Also known as Part B.

Generally, any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.

The activity conducted by State survey agencies or other CMS agents under the direction of CMS and within the scope of applicable regulations and operating instructions and under the provisions of §1864 of the Act whereby surveyors determine compliance or noncompliance of Medicare providers and suppliers with applicable Medicare requirements for participation. The survey and certification process for each provider and supplier is outlined in detail in the State Operations and Regional Office Manuals published by CMS.

The withholding of payment by an FI or carrier from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment exists.

A system for establishing goals for the rate of growth in expenditures for physicians' services.

The rules and conventions that one needs to know or follow in order to validly record information, or interpret previously recorded information, for a specific purpose. Thus, a syntax is a grammar. Such rules and conventions may be either explicit or implicit. In X12 transactions, the data-element separators, the sub-element separators, the segment terminators, the segment identifiers, the loops, the loop identifiers (when present), the repetition factors, etc., are all aspects of the X12 syntax. When explicit, such syntactical elements tend to be the structural, or format-related, data elements that are not required when a direct data entry architecture is used. Ultimately, though, there is not a perfectly clear division between the syntactical elements and the business data content.

A document published in the Federal Register notifying the public of a new or revised System of Records.

A collection of records from which an agency retrieves information by
reference to an individual identifier.

Pursuing a defined objective(s) in a planned, step by step manner.