Glossary

ABC | DEF | GHI | JKL | MNO | PQR | STU | VWXYZ

ABC

Abuse

Any incident or practice of a provider, physician, supplier, or beneficiary which, although not usually considered fraudulent, is inconsistent with accepted and sound medical, business, or fiscal practices and directly or indirectly results in unnecessary costs to the Medicare program, improper reimbursement, or program reimbursement for services that fail to meet professionally recognized standards of care which are medically necessary.

Adjudication

The process of deciding whether to pay, pend, or reject a claim based upon the information submitted, the eligibility of the recipients, and the available benefits.

Adjustment

Additional payment or correction of records on a previously processed claim.

Administrative Law Judge (ALJ)

Hearing official assigned to the Office of Hearings and Appeals. Conducts evidentiary hearings on appeals from Medicare Part A and B determinations.

Admission

Entry to a hospital or other health care institution as a patient.

Advanced Beneficiary Notice (ABN)

When the provider believes that Medicare will deny payment for a service as "not reasonable and necessary," an advance written notice to the beneficiary can protect the provider from liability.

ALJ Hearing

The ALJ hearing is a quasi-judicial administrative hearing conducted by a Federal ALJ. It results in a new decision by an independent reviewer.

Allowed Amount

The amount Medicare determines to be the maximum amount allowable for any given service. There is a 5% differential between the approved charges for services rendered by participating providers and the approved charges for services rendered by non-participating providers. The participating approved amount is 5% higher.

American Medical Association (AMA)

The national voluntary non-profit organization of professional medical personnel, composed of state and territorial medical societies and component county medical societies. The AMA attempts to speak for physicians nationally, conducts educational and publication services to members, and (with member’s dues) sponsors research to improve medical knowledge. The AMA advocates for the medical profession and for public health.

American National Standards Institute (ANSI)

A national voluntary organization of firms and private individuals who develop industry standards used in a wide variety of business applications.

Amount in Controversy

The difference between the amount charged the beneficiary less the amount the Medicare carrier allowed, less any remaining Part B Cash Deductible and/or, if applicable, Part B Blood Deductible, less 20 percent of the remainder. To meet the amount in controversy requirement, a beneficiary or provider may combine any series of claims for Part B services as long as the appeal is timely filed for all claims at issue and the claims are properly at the level of the appeal requested.

Ancillary Services

Services available to a beneficiary other than room, board and surgery, e.g., laboratory, x-ray, drugs, etc.

ANSI ASC X12 837

Industry standard for a healthcare claim (one of two formats accepted for Medicare).

ANSI ASC Z12 835

Industry standard for electronic remittance advice.

Appeal

Written or verbal statement from a customer that conveys an explicit or implicit request for review of the initial determination of a claim, or a dissatisfaction with the most recent determination.

Assignment

An arrangement whereby a provider of service or supplier agrees to accept the Medicare approved amount as full payment for services and supplies covered under Medicare Part B. Medicare usually pays 80% of the approved amount directly to the provider of service or supplier after the beneficiary meets the annual Part B deductible of $100. The beneficiary pays the other 20%.

Attending Physician

The physician rendering the major portion of care or having primary responsibility for the care of the patient’s major condition or diagnosis.

Beneficiary

Term used to identify any individual eligible for Medicare benefits.

Benefit Period

A benefit period is a way of measuring a beneficiary's use of hospital and skilled nursing facility services covered by Medicare. A benefit period begins the day the beneficiary is hospitalized. It ends after the beneficiary has been out of the hospital or other facility that primarily provides skilled nursing or rehabilitation services for 60 days in a row. If the beneficiary is hospitalized after 60 days, a new benefit period begins, most Part A benefits are renewed, and the beneficiary must pay a new inpatient hospital deductible. Benefit periods are unlimited.

Billed Amount

The amount charged for each service performed by the provider.

Calendar Year

January 1 through December 31.

Correct Coding Initiative (CCI)

The national "rebundling" initiative that ensures comprehensive and component, and mutually exclusive procedures are not separately paid.

Carrier

Private organizations, usually insurance companies, contracting with CMS to process claims under Part B of Medicare.

Centers for Medicare & Medicaid Services (CMS)

The division of the Department of Health and Human Services responsible for administering the Medicare program.

CHAMPUS

Civilian Health and Medical Program of the Uniformed Services. A federal government program embracing dependents of active duty or retired status of the Armed Forces.

Claim

A written request for payment of physician services, other medical services and supplies provided to Medicare beneficiaries.

Clearinghouse

An entity that accepts paper or electronic transactions from another organization, performs high level edits and value-added processing, then electronically routes the information to a receiving entity. Clearinghouses also perform data translations from one format to another.

CMS 855I

All physicians, non-physician practitioners and incorporated individuals who render medical services to Medicare beneficiaries and submit claims for services rendered, must complete this application. If you are planning to provide services as part of an organization/group to which you will reassign your benefits, you must also complete and submit a CMS 855R (Application for the Reassignment of Medicare Benefits).

CMS 855B

Suppliers, organizations/groups, partnerships and corporations that will bill Medicare contractors for medical services provided to Medicare beneficiaries, must complete this application. An individual whose business is incorporated, has received a tax identification number for the business, and receives Medicare payment in the name of the business would qualify as an organization.

CMS 855R

This form is to be completed by the group/partnership or group member/partner when any of the situations listed below are present:

–An individual practitioner is currently enrolled in the Medicare program and joining a group/partnership that is currently in the Medicare program and where the individual practitioner will reassign benefits to the group/partnership.

–A newly enrolling group/partnership, to list all group members/partners rendering services within the group/partnership setting.

–A Medicare group/partnership wishing to update the status of current members/partners (e.g., deleting member/partner, assigning member/partner to a new practice location, etc.) or adding a Medicare individual practitioner to the group/partnership.

–An incorporated individual reassigning Medicare benefits to the corporation.

CMS-855S

The form for Durable Medical Equipment Prosthetic Orthotic Suppliers (DMEPOS). Only available from the DMERC.

CMS-1500

Multi-purpose claim form prescribed by CMS for the Medicare program for claims from providers of service and suppliers.

COBRA

Consolidated Omnibus Budget Reconciliation Act.

Coinsurance

The portion or percentage of each Medicare approved amount a Medicare beneficiary must pay after they have paid the deductible.

Common Working File (CWF)

A query/reply system which determines a beneficiary’s deductible and entitlement status.

Comprehensive Medical Review (CMR)

A thorough analysis of a sample of processed claims and all pertinent data (such as medical records, beneficiary payment history, etc.), for selected providers, for a specified time period.

Coordination of Benefits (COB)

The determination of primary, secondary, and tertiary insurer responsibility for a patient’s health claim and the passing of claim and payment information between insurers.

Coordination Period

Specified period of time when the employer plan is the primary payer to Medicare.

Correct Coding Initiative (CCI)

The initiative for this coding is to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment.

Correspondence Control Number (CCN)

Number assigned to an inquiry or appeal (written or telephone), which is used for identification purposes.

Covered Services

Services rendered to Medicare patients that are reimbursable by the program to the provider of service or supplier.

CPT(Current Procedural Terminology)

Physicians’ Current Procedural Terminology (in other words, procedure codes, used along with HCPCS codes).

Cycle Time

Time required to pay a claim or respond to "inquiries."

DEF

Date of Service

The date the services were actually performed.

Deductible

The amount a beneficiary pays for Medicare approved expenses before Medicare starts to pay.

Denial

Determination that certain care or services cannot be reimbursed.

DHHS

Department of Health and Human Services.

Diagnosis

Identifies the condition, cause or disease of the patient (see also "ICD-9-CM").

Durable Medical Equipment (DME)

Certain medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.

Durable Medical Equipment Medicare Administrative Contractor (DME MAC)

The Medicare contractors that process claims for durable medical equipment, prosthetics, orthotics, and supplies.

EDI

Electronic Data Interchange. Refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.

EDI Enrollment Form

A CMS agreement stating that the supplier is responsible for the Medicare claims sent by itself, its employees, or its agents. Each provider of health care services, physician, or supplier that intends to submit electronic media claims (EMC) must execute this agreement. The EDI Enrollment Form must be completed prior to submitting EMC to Medicare. The signed original form must be on file for each Medicare carrier that processes your claims before production claims may be transmitted.

Electronic Funds Transfer (EFT)

Movement of funds from one bank account to another using communications networks to activate banking transactions.

Electronic Media Claims (EMC)

Transmitting claims by computer rather than submitting them on paper.

Electronic Remittance Advice (ERA)

A provider who submits claims electronically can choose to receive their Medicare Remittances electronically. ERA allows providers to systemically maintain accounts receivable when used with appropriate accounting software.

Eligible

One who is qualified to receive benefits.

Eligibility Date

Date from which benefits are available.

Employer Group Health Plan (EGHP)

Group health plan provided by a single employer of 20 or more employees or provided by an employee organization associated with that employer.

End Stage Renal Disease (ESRD)

Permanent kidney failure. That stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life.

Enrollment

The means by which one establishes membership.

Entitlement

The first date that a Medicare beneficiary can receive benefits under the Medicare program (the date of entitlement begins at age 65 for most beneficiaries).

ESRD

See End Stage Renal Disease

Explanation of Benefits (EOB)

The explanation generated by an insurance that pays BEFORE Medicare pays, i.e., Employer Group Health Plan, workers compensation, etc.

FDA

Food and Drug Administration

Federal Employee Program (FEP)

Medical program designed for federal employees and their families.

Fee-for-Service

A financing system for health care service in which a specified fee is payable for each individual service.

Fee Schedule

A list of certain services and payable amounts indicating the maximum Medicare payment for the service. Method of payment is calculated by the Resource Base Relative Value Unit Scale by which Medicare reimburses physician and non-physician services. Fee schedules are sent to providers in the fall.

Fiscal Year

October 1 through September 30.

Fraud

Intentional deception or misrepresentation which an individual or entity makes, knowing it to be false and that the deception could or does result in some unauthorized benefit.

Freedom of Information Act (FOIA)

Enacted in 1966 in order to establish the presumption that records in the possession of agencies and departments of the Executive Branch of the United States Government are accessible to the people; set standards for determining which records must be disclosed and which records can be withheld.

GHI

Gapfilling

Used when no comparable, existing test is available. Carrier specific amounts are used to establish a national limitation amount for the following year.

Group Provider Identification Number

A provider identification number assigned to an entity where more than one practitioner is rendering services. This number allows payment to be made under one name and one tax identification number.

HCPCS

Healthcare Common Procedure Coding System. HCPCS includes three levels of procedure codes as well as modifiers. Level I contains the AMA's CPT-4 codes. Level II contains alpha-numeric codes maintained by CMS. Level III contains carrier-assigned local codes.

Health Insurance Claim Number (HIC)

Identification number assigned to Medicare beneficiaries by the Social Security Administration; usually consists of the individual’s Social Security number, preceded by an alpha prefix.

Health Maintenance Organization (HMO)

A public or private organization providing, either directly or through arrangements with others, a comprehensive range of health services to enrolled members who live within a specified service area. Payment is based on a predetermined periodic rate, or periodic per capita rate, without regard to the frequency or extent of covered services furnished to any particular member. The HMO must also meet statutory requirements.

Health Professional Shortage Area (HPSA)

An area defined by the Department of Health and Human Services, Public Health Service Division of Shortage Designation, as having a shortage of health professionals. A HPSA can be urban or rural.

Home Health Agency

An approved association or organization where a Medicare patient receives skilled nursing and/or therapeutic care in the home.

Hospice Care

Care provided for beneficiaries who have a terminal illness with a life expectancy of six months or less; these beneficiaries have the option of electing hospice coverage instead of the standard Medicare coverage.

Hospital

Institution with organized medical staff, with permanent facilities that include inpatient beds; and with medical services, including physician services and continuous nursing services, to provide diagnosis and treatment for patients who have a variety of medical conditions, both surgical and non-surgical.

ICD-9-CM

International Classification of Diseases Clinical Modification (in other words, diagnosis codes).

Intelligent Character Recognition (ICR)

A system used to capture claim information directly from the CMS–1500 claim form; all information which is captured by the computer is transferred into an electronic file which is then passed to the Medicare claims processing system.

Inquiry

All claimant oral and written contacts which do not request a reexamination of or state a dissatisfaction with the previous determination (in other words, an appeal). Usually pertains to claim status or general information such as deductible, entitlement, etc.

Internal Control Number (ICN)

A 13-digit number assigned to a claim, which is used for identification purposes and retrieval purposes, if necessary.

JKL

Joint Commission on Accreditation of Healthcare Organizations

An organization that accredits healthcare organizations. In the future, the JCAHO may play a role in certifying these organizations' compliance with the HIPAA A/S requirements.

Julian Date

A three-digit number indicating the day of the year. January 1 is 001 and December 31 is 365 or 366.

Large Group Health Plan (LGHP)

A plan provided by an employer who employs 100 or more persons or a plan belonging to a multi-employer plan where at least one employer has 100 or more full or part time employees.

Limitation of Liability

A provision designed to protect the beneficiary from liability under certain conditions when services he/she received are found not to be reasonable and necessary.

Limiting Charge

Congress-enacted law which limits what a physician may charge Medicare beneficiaries for medical services; every charge on a NON-ASSIGNED Medicare claim for physician’s services is subject to a legal limit called the limiting charge; these physician charges to a Medicare beneficiary may not exceed the maximum of 115% of the Medicare allowed amount for any service or procedure rendered.

Limiting Charge Monitoring Report (LCMR)

A retrospective review and notice sent to those providers who fail to meet acceptable levels of limiting charge compliance; these non-compliance notices are mailed after completion of a monthly review of the Limiting Charge Exception Report files.

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.

MNO

Medicaid

A medical coverage program jointly funded by both the states and the federal governments; for those residents who qualify because of an annual income which falls below the state or nationally indicated poverty level.

Medical Review

The review of medical records or information as it relates to services rendered and billed by a provider or beneficiary for payment. This review is performed by the medical staff of physicians, registered nurses, licensed practical nurses, etc.

Medically Necessary

The level of services and supplies (frequency, extent and type) that is adequate for the diagnosis and treatment of illness or injury. Medical necessity includes the concept of appropriate medical care.

Medicare

A Federal health insurance program which provides coverage for people 65 and older, for certain disabled people, and for some people with End Stage Renal Disease (ESRD); enacted into law in 1965 by Congress through Title XVIII of the Federal Social Security Act, and managed by the Centers for Medicare & Medicaid Services (CMS), a branch of the Department of Health and Human Services (DHHS).

Medicare Advantage

This the new name for Medicare + Choice Plans, such as your HMOs, PPOs, Private Fee-for-Service Plans or Medicare Specialty Plans. Medicare Advantage give you more health care coverage choices and better health care benefits.

Medicare Advantage Drug Plan (MA-PD)

Some Medicare Advantage Plans will include coverage for a prescription drug plan.

Medicare Entitlement

When an individual becomes entitled to Medicare, he/she receives a Health Insurance Claim card which shows his/her name, sex, Medicare number, and the effective dates of entitlement to hospital (Part A) benefits and medical (Part B) benefits. Entitlement begins the first day of the month of the individual’s birth and ends the last day of the month, with the exception of death.

Medicare Modernization Act (MMA)

On December 8, 2003, President George W. Bush signed into law the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Pub. L. 108-173). This landmark legislation provides seniors and individuals with disabilities with a prescription drug benefit, more choices, and better benefits under Medicare.

Medicare Remittance Notice (MRN)

A summarized statement for providers including payment information for one or more beneficiaries.

Medicare Secondary Payer (MSP)

There is another insurance company that is primary to Medicare; the primary insurance company pays first and Medicare would be secondary payer for the service(s).

Medigap

A Medicare supplemental insurance policy or other health benefit plan offered by a private company to those entitled to Medicare benefits. These plans provide reimbursement for Medicare approved charges not reimbursable because of the applicability of deductible, co-insurance amounts or other Medicare imposed limitations.

Modifiers

Two digit codes that indicate services or procedures have been altered by some specific circumstance. Modifiers do not change the definition of the reported procedure codes.

National Provider Identifier (NPI)

A unique standardized identifier for a providers and suppliers of health care services, as required under the Administrative Simplification are of the Health Insurance Portability and Accountability Act (HIPAA). The NPI consists of an eight digit alphanumeric identifier plus a two digit alphanumeric location identifier to indicate the provider’s practice location. NPIs are good for life and only the location identifier may change. NPI has not yet been implemented.

NCPDP

National Council for Prescription Drug Programs Telecommunications Standard Format 3.2 or 4.0

Non-assigned Claim

A claim for which the suppliers do not agree to accept Medicare's allowed charges; the supplier bills the beneficiary for all charges, and then submits claim as non-assigned; Medicare sends any payment to the beneficiary.

Non-covered Services

Services which Medicare does not pay for, but the patient does.

Non-participating Provider

Physicians/suppliers who do not sign an agreement to accept assignment on all Medicare claims. They may accept assignment on a claim-by-claim basis and may bill the patient up front for non-assigned claims.

Office of the Inspector General (OIG)

Government office that is responsible for monitoring and investigating abuse and fraud.

Offset

The recovery by Medicare of a debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness.

Ordering Physician

The physician that orders an item or service.

PQR

Part A (Hospital Insurance)

Coverage which helps pay for inpatient hospital care, some inpatient care in a skilled nursing facility, some home healthcare, and hospice care. Hospitals submit their claims to their Part A intermediaries; usually premium free with a deductible per benefit period.

Part B (Medical Insurance)

Coverage which helps pay for medical and surgical services by physicians, providers of service, and suppliers, as well as certain other health benefits such as ambulance transportation, durable medical equipment, outpatient hospital services, and independent laboratory services; designated to complement the coverage provided by Part A of the program; beneficiaries pay a premium and are responsible for an annual deductible.

Participating

An eligible provider or supplier who has entered into an agreement to accept assignment for all services rendered to Medicare patients, and to accept the Medicare approved amount as payment in full for all services rendered. A participating provider or supplier may not collect from the beneficiary more than the applicable deductible and coinsurance for covered services.

Participating Physician/Supplier

A doctor or supplier who agrees to accept assignment on all Medicare claims. These doctors or suppliers may bill only for the unmet Medicare deductible and/or coinsurance amounts.

Patient Eligibility

Requirements entitling individuals to Medicare benefits.

Patient

A person under treatment or care, as by a physician or surgeon, or in a facility.

Payers

People or businesses that have purchased coverage and/or paid for health care services (government, employers, and insurers).

Payment Floor

The timeframe established for contractor payment of Medicare Part B and DME claims. Electronically submitted claims are paid a minimum of 13 days after the date of receipt, while paper claims will be paid a minimum of 27 days after the date of receipt. All clean claims (claims which do not require additional development or other documentation for processing), whether electronic or paper, must be processed within 30 days of receipt or the carrier will be required to pay interest in addition to allowances for covered services.

Physician's Assistant

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

Place of Service

Where a service was performed, for example, inpatient hospital, outpatient hospital, doctor’s office, etc.

Postpayment Review

The review of a claim after a determination and payment has been made to the provider or beneficiary.

Practitioner

An individual who provides health care services; physicians and non-physicians. This not does include service companies.

Premium

The amount paid by a Medicare beneficiary to obtain Part B (medical) insurance, or in some cases Part A (hospital) insurance.

Prescription Drug Plan (PDP)

Medicare prescription drug plan benefit, will provide insurance coverage for prescription drugs. Like other insurance, if you enroll you will pay a monthly premium.

Primary Payer

An insurance policy, plan, or program that pays first on a claim for medical care. This could be Medicare or other health insurance.

Privacy Act of 1974

Act which regulates federal government agency record keeping and disclosure practices. Without the written consent of the individual, the Privacy Act prohibits release of protected health information maintained in a system of records unless 1 of the 12 disclosure provisions applies.

Procedure Code

A HCPCS code used by a physician or provider of services to describe the procedure or service rendered to the patient.

Professional Component (PC)

The physician work portion of diagnostic tests (e.g. interpretation).

Prolonged Physician Services

Physician services involving direct (face-to-face) patient contact beyond that of the usual service.

Prospective Payment System (PPS)

A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, DRGs for inpatient hospital services).

Protected Health Information (PHI)

Individually identifiable health information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate. Identifies the individual or offers a reasonable basis for identification. Is created or received by a covered entity or an employer. Relates to a past, present, or future physical or mental condition, provision of health care or payment for health care.

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 medical services covered under Medicare Part B. Any organization, institution, or individual that provides health care services to Medicare beneficiaries. Physicians, ambulatory surgical centers, and outpatient clinics are some of the providers of services covered under Medicare Part B.

Provider Identification Number (PIN)

An identification number assigned to providers by the carrier; required for any provider, regardless of participation status, who wishes to submit claims to Medicare for reimbursement.

Provider Outreach & Education (POE) Advisory Group

A group within the DME MAC A to assist in the creation, implementation, and review of contractor provider/supplier education strategies and efforts. The POE Advisory Group provides input and feedback on training topics, provider/supplier education materials, and dates and locations of provider/supplier education workshops and events.

Purchased Diagnostic Tests

A test (such as an ECG, x-ray, ultrasound, etc.) purchased from an outside supplier for which a physician bills, but does not personally perform or supervise.

Qualified Independent Contractor (QIC)

All second-level appeals, also known as reconsiderations, are conducted by Qualified Independent Contractors (QICs).

Rebundling

A comprehensive standardized package of computerized edits to identify and prevent improper reporting on a national level.

Reconsideration

A reconsideration is the second level in the Medicare appeals process. An appellant may file a request for reconsideration if he or she is dissatisfied with the results of the Medicare contractor's redetermination.

Recoupment

The recovery by Medicare of any Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness.

Redetermination

The first formal level of appeal following the initial processing of a Part B claim.

Referring Physician

A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Rejected/Returned Claim

Process where a claim is returned/rejected because essential information such as the ICD-9-CM Code or HCPCS code is missing or incomplete. The claimant must resubmit the claim and may not bill the beneficiary until Medicare gives the claimant a decision. Otherwise known as an "unprocessable claim".

Reopening

A re-evaluation of a claim which is a discretionary action in response to the identification of a minor clerical error or omission after submission of the claim. If a supplier has made a minor error or omission when filing a claim, which results in a denial of the claim, the supplier must not request a redetermination. It is not an appeal right.

Resource Based Relative Value Scale (RBRVS)

A scale which assigns values to procedures in relation to one another; used to establish the Medicare Fee Schedule.

Review

The first formal level of appeal following the initial processing of a Part B claim. It is a second look at the claim and supporting documentation by a different employee.

Revised Determination or Decision

A revised determination or decision is one in which:

The end result is changed (for example, a service previously found to be not covered is now found to be covered or the reasonable charge allowed for the service is determined to be incorrect); or

The end result is not changed, but a party might be disadvantaged by the revision (for example, a request for payment on an assigned claim previously disallowed because the services were not medically necessary and therefore subject to the waiver of liability provisions, is now to be disallowed on a basis that precludes consideration of waiver of liability).

Roster Billing

Simplified billing process used when a provider accepts assignment and bills for mass immunizations.

STU

SADMERC

The Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) is a national entity that provides services under contract to the Centers for Medicare & Medicaid Services (CMS). The SADMERC Reports and Analysis Unit provides data analysis support to the Durable Medical Equipment (DME) Program Safeguard Contractors (PSCs).

Secondary Payer

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

Site of Service Differential

Payment for some services that are routinely furnished in physicians’ offices are reduced when such services are furnished in the following hospital settings: Outpatient Hospital; Emergency Room-Hospital; Comprehensive Outpatient Rehabilitation Facility; ESRD Treatment Facility; and effective for 1994 dates of service, the following settings: Inpatient Hospital; Inpatient Psychiatric Facility; and Comprehensive Inpatient Rehabilitation Facility.

Skilled Nursing Facility (SNF)

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.

Social Security Act

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.

Social Security Administration (SSA)

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

State Law

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

Surrogate UPIN

A temporary UPIN that a provider may use until one is assigned.

Team Surgery

A single surgical procedure which requires the skills of more than two surgeons of different specialties, working together to carry out various portions of a complicated surgical procedure.

Technical Component (TC)

The performance of a diagnostic test, that is, staff and equipment costs.

TEFRA

Tax Equity and Fiscal Responsibility Act of 1982.

Third Party Liability (TPL)

When a Beneficiary sues another party due to an accident, such as a fall on someone’s property.

Time Limit

The specified period of time during which a notice of claim or appeal must be filed.

Title XVIII

The title of the Social Security Act which contains the principal legislative authority for the Medicare program, and therefore, a common name for the program.

Unassigned Claim

A claim submitted for a service or supply by a provider who does not accept assignment.

Unfavorable Determination

A determination or decision is "unfavorable" if, for initial decisions, it is a complete denial of coverage/payment, or, for subsequent appeals, it fails to advance the interests of the claimant.

Unique Provider Identification Number (UPIN)

A six character identifier (one alpha, five numeric) assigned to physicians by the Centers for Medicare & Medicaid Services.

Unprocessable Claim

Process where a claim is returned/rejected because essential information such as the ICD-9-CM Code or HCPCS code is missing or incomplete. The claimant must resubmit the claim and may not bill the beneficiary until Medicare gives the claimant a decision. These rejections may not be appealed.

VWXYZ

ViPS Medicare System (VMS)

A comprehensive healthcare claims system used in the processing of the professional payment component of the Medicare Program.

ViPS Provider Inquiry System (VPIQ)

A subsystem of the VIPS Medicare System (VMS) that allows suppliers to obtain information on claim status by health insurance claim number (HICN) and date of service, paid/denied claim information, information on completed claims awaiting payment floor clearance, estimated mail or electronic funds transfer (EFT) date on completed claims, and eligibility.

Waiver of Liability Provision

A provision which states that if the provider informed the beneficiary in writing before the item or service was furnished that Medicare is likely to deny payment for the item or service rendered as "not reasonable and necessary," and obtained his or her agreement to pay, the provider’s liability is waived and payment is made to the provider by the beneficiary.

Working Aged

Employed individuals aged 65 or over and individuals aged 65 or over with employed spouses of any age.

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