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Glossary
| Term | Definition |
|---|---|
| Beneficiary | The name for a person who has health care insurance through the Medicare or Medicaid program. |
| Carrier | A private company that has a contract with Medicare to pay your Medicare Part B bills. (See Part B.) |
| Centers for Medicare & Medicaid Services (CMS) (formerly Health Care Financing Administration (HCFA)) | The federal agency within the Department of Health and Human Services (DHHS) established to administer the Medicare, Medicaid, and State Children's Health Insurance Programs. |
| Coordination of Benefits (COB) | A program that determines which plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits. If one of the plans is a Medicare health plan, Federal law may decide who pays first. |
| Electronic Media Questionnaire (EMQ) | A process that large employers can use to complete their requirements for supplying IRS/SSA/CMS Data Match information electronically. |
| Employee | For purposes of the Medicare Secondary Payer (MSP) provisions, an employee is an individual who works for an employer, whether on a full- or part-time basis, and receives payment for his/her work. |
| Employer | Individuals and organizations engaged in a trade or business, plus entities exempt from income tax such as religious, charitable, and educational institutions, the governments of the United States, Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, and the District of Columbia, and the agencies, instrumentalities, and political subdivisions of these governments. |
| Employer Bulletin Board Service (BBS) | An electronic bulletin board service offered by the COB Contractor. Employers that have to report on less than 500 workers can fulfill their requirements under the Internal Revenue Service/Social Security Administration/Centers for Medicare & Medicaid Services (IRS/SSA/CMS) Data Match law by downloading a questionnaire entry application from the bulletin board. The information will be processed through several logic and consistency edits. Once the employer has completed the information, he or she will return the completed file through the bulletin board. |
| End-Stage Renal Disease (ESRD) | Kidney failure that is severe enough to require lifetime dialysis or a kidney transplant. |
| Group Health Plan (GHP) | A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization. |
| Health Insurance Claim Number (HICN) | The number assigned by the Social Security Administration to an individual identifying him/her as a Medicare beneficiary. This number is shown on the beneficiary’s insurance card and is used in processing Medicare claims for that beneficiary. |
| Health Maintenance Organization (HMO) | A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. In an HMO, you usually must get all your care from the providers that are part of the plan. |
| Initial Enrollment Questionnaire (IEQ) | A questionnaire sent to you when you become eligible for Medicare to find out if you have other insurance that should pay your medical bills before Medicare. |
| Insurer | An insurer of a GHP is an entity that, in exchange for payment of a premium, agrees to pay for GHP-covered services received by eligible individuals. |
| Interactive Voice Response Unit (IVR) | A voice processing system developed to allow a caller to access an automated voice response through a touch-tone phone instead of speaking to a live telephone representative. The IVR provides the caller with an interactive menu where they can get general Medicare-COB information, inquire about the status of their IEQ or Data Match questionnaire, elect Electronic Filing, request an extension or a duplicate questionnaire, or speak to a representative. |
| Intermediary | A private company that has a contract with Medicare to pay Part A (hospital) and some Part B bills. |
| Internal Revenue Service/ Social Security Administration/ Centers for Medicare & Medicaid Services Data Match (IRS/SSA/CMS Data Match) | A process by which information on employers and employees is provided by the IRS and SSA and is analyzed by CMS for use in contacting employers concerning possible periods of MSP. This information is used to update the CWF-Medicare Common Working File. |
| Medicare | The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD). |
| Medicare Part A (also known as Hospital Insurance Part A) | Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care. |
| Medicare Part B (also known as Medical Insurance Part B) | The part of Medicare that pays doctors’ services and outpatient hospital care. It also covers other medical services that Part A does not cover, like physical and occupational therapy. |
| Medicare Secondary Payer (MSP) | A statutory requirement that private insurers providing general health insurance coverage to Medicare beneficiaries pay beneficiary claims as primary payers. |
| Multi-Employer Group Health Plan | A group health plan that is sponsored jointly by two or more employers or by employers and employee organizations. |
| Multiple Employer Plan | A health plan sponsored by two or more employers. These are generally plans that are offered through membership in an association or a trade group. |
| Permanent Kidney Failure | Kidney failure that is severe enough to require lifetime dialysis or a kidney transplant. (See also End-Stage Renal Disease) |
| Provider | Any Medicare provider (e.g., hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, physician, non-physician provider, laboratory, supplier, etc.) providing Medicare services covered under Medicare Part B. |
| Secondary Claim Development (SCD) | When a claim is submitted with an explanation of benefits (EOB) attached from an insurer other than Medicare, a questionnaire is sent to the beneficiary to collect information on the existence of other insurance that may be primary to Medicare. |
| Social Security Administration (SSA) | The Federal agency that, among other things, determines initial entitlement to and eligibility for Medicare benefits. |
| Supplier | Generally, any company, person, or agency that gives you a medical item or service; like a wheelchair or walker. |
| Third Party Administrator (TPA) | An entity required to make or responsible for making payment on behalf of a group health plan. |
| Trauma Development (TD) | When a diagnosis appears on a claim that information is received through correspondence or on a claim that indicates a traumatic accident, injury, or illness, which might form the basis of MSP, a questionnaire is sent to collect information on the existence of other insurance that may be primary to Medicare. This questionnaire may be sent to the beneficiary, provider, attorney, or insurer. |
| Voluntary Data Sharing Agreement | An agreement between CMS and insurers or employers to exchange Medicare information and group health plan eligibility information for the purpose of coordinating health benefit payments. |
Last Modified on Friday, September 17, 2004
Centers for Medicare & Medicaid Services