|
ADJ |
Adjustment – Additional
payment or corrections of records on a previously processed claim |
|
ALJ |
Administrative Law Judge - A
hearings officer who presides over appeal conflicts between providers of
services, or beneficiaries, and Medicare contractors |
|
BBA |
Balanced Budget Act – Law
that changed sections of the Social Security Act, including several
anti-fraud and abuse provisions and improvements to protect program
integrity |
|
BENE |
Beneficiary - The name for a
person who has health care insurance through the Medicare or Medicaid
program |
|
CFR |
Code of Federal Regulations –
The codification of the general and permanent rule published in the Federal
Register by the executive departments and agencies in the Federal
Government.
www.gpoaccess.gov/cfr/index.html or go to
www.cms.gov/hhs/gov
and click on ‘regulations’. |
|
CCN |
Correspondence Control Number
– A thirteen digit number stamped to each piece of correspondence. |
|
CHAMPUS |
Civilian Health and Medicare
Program Run by the Department of Defense, in the past CHAMPUS gave medical
care to active duty members of the military, military retirees, and their
eligible dependents. (This program is now called "TRICARE"). |
|
CIA |
Corporate Integrity Agreement |
|
CMS |
Centers for Medicare and
Medicaid Services - The federal agency that runs the Medicare program. In
addition, CMS works with the States to run the Medicaid program. CMS works
to make sure that the beneficiaries in these programs are able to get high
quality health care. |
|
COB |
Coordination of Benefits - 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. |
|
COBRA |
Consolidated Omnibus Budget
Reconciliation Act - A law that lets some people keep their employer group
health plan coverage for a period of time after: the death of your spouse,
losing your job, having your working hours reduced, leaving your job
voluntarily, or getting a divorce. You may have to pay both your share and
the employer’s share of the premium. Generally, you also have to pay an
administrative fee. |
|
COBC |
Coordination of Benefits
Contractor |
|
CONDITIONAL PAYMENT |
A Medicare payment for
services for which another insurer is primary payer. Conditional Primary
Medicare Benefits: conditional primary Medicare benefits may be paid if:
- The beneficiary, the physician, or the supplier has filed a proper
claim with a TPP in the case of services for which payment under WC or
no-fault insurance can reasonably be expected, and you determine that the
insurer will not pay promptly
- The beneficiary, the provider, or the supplier that has accepted
assignment filed a proper claim with a GHP or LGHP and the TPP denied the
claim in whole or in part; or
- Because of physical or mental incapacity of the beneficiary, the
physician, supplier, or beneficiary failed to file a proper claim with the
TPP.
|
|
CWF |
Common Working File – The
Medicare Part A and B benefit coordination system that uses localized data
bases maintained by a host contractor. |
|
DCIA |
Debt Collection Improvement
Act |
|
DCC |
Department of Debt Collection |
|
DHHS |
Department of Health and
Human Services. DHHS administers many of the "social" programs at the
Federal level dealing with the health and welfare of the citizens of the
United States. (It is the "parent" of CMS). |
|
DOJ |
Department of Justice |
|
ECRS |
Electronic Correspondence
Referral System – A system which allows Medicare MSP representatives and
authorized CMS Regional Offices to fill out various online forms and
electronically submit requests for changes to existing CWF MSP information. |
|
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. |
|
EDS |
Electronic Data System |
|
EFT |
Electronic Funds Transfer –
Electronic transfer of Medicare payments directly to a provider’s financial
institution. |
|
EGHP |
Employer Group Health Plan. A
GHP is a health plan that 1) Gives health coverage to employees, former
employees, and their families, and 2) Is from an employer or employee
organization. |
|
EIN |
IRS Employer Tax Id Number |
|
EMC |
Electronic Media Claims –
This term usually refers to a flat file format used to transmit or transport
claims, such as the 192-byte UB-92 Institutional EMC format and the 320-byte
Professional EMC NSF. |
|
EOB |
Explanation of Benefits – A
notice from an insurance company explaining what benefits were paid on a
charge and giving an explanation as to why the benefits were paid or denied. |
|
ERA |
Electronic Remittance Advice
– Any of several electronic formats for explaining the payments of health
care claims |
|
ERN |
Electronic Remittance Notice
– Electronic summarized statement for providers |
|
ESRD |
End Stage Renal Disease -
Medicare is secondary to GHPs (without regard to the number of individuals
employed and irrespective of current employment status) that cover
individuals who have ESRD. GHPs are always primary payers throughout the
first 30 months of ESRD- based on Medicare eligibility or entitlement.
|
|
EXECUTOR OF ESTATE |
The person appointed by the
testator to execute his/her will is an "Executor of the Estate" |
|
FAQ |
Frequently Asked Question |
|
FBI |
Federal Bureau of
Investigation |
|
FI |
Fiscal Intermediary – A
private company that has a contract with Medicare to pay Part A and some
Part B bills. (Also called "Intermediary.") |
|
GHP |
Group Health Plan means any
arrangement of, or contributed to by, one or more employers, or employee
organizations, to provide health benefits or medical care directly or
indirectly to current or former employees, the employer, others associated
or formerly associated with the employer in a business relationship, or
their families. An arrangement by more than one employer is considered to be
a single plan if it provides for common administration of the health
benefits (e.g., by the employers directly or by a benefit administrator or
by a multi-employer trust or by an insuring organization under a contract or
contracts). A plan that does not have any employees or former employees as
enrollees (e.g., a plan for self-employed persons only) does not meet the
definition of a GHP, and Medicare is not secondary to it. Thus, if an
insurance company establishes a plan solely for its self-employed insurance
agents, other than full-time life insurance agents, the plan is not
considered a GHP. However, if the plan includes full-time life insurance
agents or other employees or former employees, it is considered a GHP.
The term "GHP" includes self-insured plans, plans of governmental
entities (Federal, State and local, such as the Federal Employees Health
Benefits Program), and employee organization plans. Examples of the later
are union plans and employee health and welfare funds. Employee-pay-all
plans are also included (i.e., GHPs that are under the auspices of one or
more employers or employee organizations but do not receive any contribution
from the employer). However, coverage under the Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS) is secondary to Medicare since
the law makes Medicare primary to CHAMPUS.
Any health plan (including a union plan) in which a beneficiary is
enrolled because of his/her own employment or a family member's employment
meets this definition. |
|
HCFA |
Health Care Finance
Administration (now CMS) |
|
HIC |
Health Insurance Claim number
– 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. |
|
HIMR |
Health Insurance Master
Record |
|
HMO |
Health Maintenance
Organization – 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. You usually must get your care from the providers in the plan. |
|
HIPAA |
Health Insurance Portability
and Accountability Act – A Federal law that allows persons to qualify
immediately for comparable health insurance coverage when they change their
employment relationships. Title II, Subtitle F, of HIPAA gives HHS the
authority to mandate the use of standards for the electronic exchange of
health care data; to specify what medical and administrative code sets
should be used within those standards; to require the use of national
identification systems for health care patients, providers, payers (or
plans), and employers (or sponsors); and to specify the types of measures
required to protect the security and privacy of personally identifiable
health care information. Also known as the Kennedy-Kassebaum Bill, the
Kassebaum-Kennedy Bill, K2, or Public Law 104-191. |
|
IEQ |
Initial enrolment
questionnaire – A questionnaire sent to a beneficiary when he/she becomes
eligible for Medicare to find out if he/she has other insurance that should
pay his/her medical bills before Medicare. |
|
IRS |
Internal Revenue Service |
|
LGHP |
LGHP means a GHP that covers
employees of either:
- A single employer or employee organization that employed at least 100
full-time or part-time employees on 50 percent or more of its regular
business days during the previous calendar year; or
- Two or more employers or employee organizations at least one of which
employed at least 100 full-time or part-time employees on 50 percent or
more of its regular business days during the previous calendar year.
|
|
LIABILITY INSURANCE |
Liability Insurance
(including a self-insured plan) provides payment based upon a legally
established responsibility for injury, illness, or damage to property. This
includes, but is not limited to, automobile liability, uninsured and
under-insured motorist, home owner's liability, malpractice, product
liability, and general casualty insurance. It may also include payments
under state "wrongful death" statutes that provide payment for medical
damages. |
|
MED-PAY |
Is a payment made by an
insurer intended specifically to pay for medical expenses without regard to
the fault of any part to the accident. Med-Pay is a form of no-fault
insurance. In these situations, Medicare's proportionate share of
procurement costs are not deducted from this payment unless the claim was
contested. |
|
MEDICAL MALPRACTICE |
Medical malpractice is
defined as a dereliction from medical professional duty or failure to
exercise an accepted degree of medical professional skill or learning
rendering medical services which result in injury, loss, or damage.
|
|
MSP |
Medicare Secondary Payer - A
statutory requirement that private insurers providing general health
insurance coverage to Medicare beneficiaries pay beneficiary claims as
primary payers. |
|
MSN |
Medicare Summary Notice - A
notice the beneficiary gets after a doctor or provider files a claim for
Part A and Part B services in the Original Medicare Plan. It explains what
the provider billed for, the Medicare-approved amount, how much Medicare
paid, and what the beneficiary must pay. |
|
NO-FAULT |
Medicare is secondary to any
no-fault insurance, including automobile medical and non-automobile no-
fault insurance. |
|
OBRA |
Omnibus Budget Reconciliation
Act |
|
OIG |
Office of Inspector General –
An organizational component of the Office of the Secretary, DHHS which is
responsible for conducting and supervising audits, investigation, and
inspections relating to the programs and operations of the DHHS including
Medicare and Medicaid. |
|
PARTIAL WAIVER |
A Partial Waiver is a
decision by the Medicare program to relinquish the right to collect from a
specific party. A partial waiver is not to be confused with a compromise,
however, as they are different. A partial waiver does not arise from
negotiation or offer, but under Medicare guidelines. These guidelines
provide the beneficiary (their representative or an entitled surviving
spouse/dependent or child) the right to request a waiver, as well as
providing Medicare with the authority to grant or deny the request based on
data. |
|
PIP |
Personal Injury Payment – A
payment made by an insurer intended to be used for any bill related to the
accident. The payment is not limited to the payment of medical bills only.
|
|
PLAINTIFF |
A plaintiff is one who
commences a personal action or lawsuit to obtain a remedy for an injury to
his/her rights. The plaintiff is the complaining party in litigation.
|
|
PRE-SETTLEMENT |
In liability situations,
pre-settlement refers to the time period before a settlement has been
reached on the case. |
|
PROCUREMENT COSTS |
Procurement costs include
attorney fees and other costs directly related to securing a settlement or
judgment that are the responsibility of the party against which CMS seeks to
recover. "Other costs" may include postage, telephone calls, medical record
acquisition, expert witnesses, or any other charge incurred by the attorney
to recover Medicare overpayments. |
|
PRODUCT LIABILITY |
Product liability is a
manufacturer's liability for their product. Common product liability cases
involve silicone breast implants, pacemakers, etc. |
|
PROMPT PAYMENT |
Prompt Payment or promptly
with regard to liability insurance means payment within 120 days after the
earlier of the following:
- The date a claim is filed with an insurer or a lien is filed against a
potential liability settlement; or
- The date the service was furnished or, in the case of inpatient
hospital services, the date of discharge.
- With regard to all other primary payers, prompt or promptly means
payment within 120 days after receipt of the claim.
|
|
PROPER CLAIM |
Proper Claim means a claim
that is filed timely and meets all other claims filing requirements
specified by the TPP. |
|
RA |
Remittance Advice -
Summarized statements for providers including payment information for one or
more beneficiaries. |
|
SECONDARY |
Secondary – when used to
characterize Medicare benefits, means benefits that are payable only to the
extent that payment has not been made and cannot reasonably be expected to
be made by a TPP that is primary to Medicare. |
|
SELF INSURED PLAN |
A plan under which an
individual or a private or government entity carries its own risk instead of
taking out insurance with a carrier. The term includes a plan of an
individual or other entity engaged in a business, trade, or profession; a
plan of an organization such as a social, fraternal, labor, educational,
religious, or professional organization; and the plan established by the
Federal Government to pay for liability claims under the Federal Tort Claims
Act (FTCA). (With regard to FTCA claims, CMS attempts to collect its
mistaken payment from the Federal agency that is settling the claim. If a
resolution cannot be reached, CMS must submit the conflict to the Department
of Justice for resolution.) |
|
SETTLEMENT |
An adjustment or agreement by
which parties having a dispute reach an agreement is known as a
"settlement". In MSP, the term 'settlement' refers to an amount from a
liability insurer or other responsible party to satisfy the liability
dispute. |
|
STATUTE OF LIMITATIONS |
The Statute of Limitations is
a law assigning a certain time after which rights cannot be enforced by
legal action, meaning offenses can not be punished.
Certain claims must be filed within the specific time period after the
right to assert a claim begins. The claim can no longer be enforced if it is
filed too late (when the time frame has ended). |
|
SUBPOENA |
A subpoena is a writ (legal
order) commanding a designated person to appear in court. A penalty may be
assessed if the individual specified in the subpoena fails to appear in
court. |
|
TEFRA |
Tax Equity and Fiscal
Responsibility ACT |
|
TORT |
A "tort" is a wrongful act
for which a civil action will lie, except one that involves a breach of
contract. A Federal Tort case is one in which the beneficiary and/or the
beneficiary's attorney or other representative are alleging that a federal
entity is the liable party. |
|
TPP |
Third Party Plan means a WC
law or plan, automobile or non-automobile no-fault insurance, any liability
insurance, or a GHP or LGHP that is required to pay primary to Medicare.
|
|
TTY |
Teletypewriter is a
communication device used by people who are deaf, hard of hearing, or have
severe-speech impairment. A TTY consists of a keyboard, display screen, and
modem. Messages travel over regular telephone lines. People who don’t have a
TTY can communicate with a TTY user through a message relay center (MRC). An
MRC has TTY operators available to send and interpret TTY messages. |
|
UPIN |
Unique Provider
Identification Number – A six character alpha numeric code assigned by CMS
to each Medicare provider and used to identify a referring physician. |
|
UNDERINSURED |
The term "underinsured"
refers to being insufficiently insured (too little insurance). |
|
UNINSURED |
The term "uninsured" refers
to not being insured (no insurance at all). |
|
UTILIZATION |
The term "utilization" refers
to the used amount.
Specifically, when Medicare conditional payments are recovered, the
services paid conditionally are not counted against the number of inpatient
care days available to the beneficiary.
If an individual is hospitalized twice in the same benefit period and
Medicare recovers its payment from the liability insurance for the first
hospitalization, the first hospitalization would not be charged to the
beneficiary. |
|
VA |
Veterans Administration |
|
WAIVER |
A waiver is the forgiveness
of a party's obligation to satisfy Medicare's claim, in whole or in part, if
certain conditions are met. |
|
WORKING AGED |
Medicare is secondary to
group health plans (GHPs) of employers and employee organizations, including
multi-employer and multiple employer plans which have at least one
participating employer that employs 20 or more employees. Medicare is
secondary for Medicare beneficiaries age 65 or older who are covered under
the plan by virtue of their own current employment status with an employer
or the current employment status of a spouse of any age. |
|
WORKERS’ COMPENSATION |
Medicare is secondary to WC
plans (including black lung benefit programs) of the States and the United
States. |
|
WRONGFUL DEATH |
Wrongful death is a death
caused by a wrongful act, neglect, or fault as seen in some liability
situations. |
