Glossary

Means the number of patients served by a physician or physician group. If the panel size 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.

A test to check for cancer of the cervix, the opening to a woman's womb. It is done by removing cells from the cervix. The cells are then prepared so they can be seen under a microscope.

Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care. (See Hospital Insurance (Part A).)

Medicare Hospital Insurance also referred to as "HI."
Part A is the hospital insurance portion of Medicare. It was established by �1811 of Title XVIII of the Social Security Act of 1965, as amended, and covers inpatient hospital care, skilled nursing facility care, some home health agency services, and hospice care.

A monthly premium paid by or on behalf of individuals who wish for and are entitled to voluntary enrollment in the Medicare HI program. These individuals are those who are aged 65 and older, are uninsured for social security or railroad retirement, and do not otherwise meet the requirements for entitlement to Part A. Disabled individuals who have exhausted other entitlement are also qualified. These individuals are those not now entitled but who have been entitled under section 226(b) of the Act, who continue to have the disabling impairment upon which their entitlement was based, and whose entitlement ended solely because the individuals had earnings that exceeded the substantial gainful activity amount (as defined in section 223(d)(4) of the Act).

Medicare medical insurance that helps pay for doctors? services, outpatient hospital care, durable medical equipment, and some medical services that aren?t covered by Part A.

Medicare medical insurance that helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Part A. (See Medical Insurance (Part B).)

Medicare Supplementary Medical Insurance also referred to as "SMI." Medicare insurance that pays for inpatient hospital stay, care in a skilled nursing facility, home health care, and hospice care.
Part B is the supplementary or "physicians" insurance portion of Medicare. It was established by 1831 of the Title XVIII of the Social Security Act of 1965 as amended, and covers services of physicians/other suppliers, outpatient care, medical equipment and supplies, and other medical services not covered by the hospital insurance part of Medicare.

A plan is paid for providing services to enrollees through a combination of capitation and fee for service reimbursements.

A structured program of active treatment for psychiatric care that is more intense than the care you get in your doctor?s or therapist?s office.

A stipulated dollar amount established for certain health care services while other services are reimbursed on a cost or fee-for-service basis.

Those hospitals that participate in the Medicare program.

A doctor or supplier who agrees to accept assignment on all Medicare claims. These doctors or suppliers may bill you only for Medicare deductible and/or coinsurance amounts. (See Assignment.)

A hospital employee whose job is to speak on a patient?s behalf and help patients get any information or services they need.

Equipment to move a patient from a bed or wheelchair using your strength or a motor.

The clinical and statistical analysis of data sets. Frequently used ESRD data sets include the PMMIS, USRDS, the core indicators, Network files, or CMS analytic files.

A financing scheme in which taxes are scheduled to produce just as much income as required to pay current benefits, with trust fund assets built up only to the extent needed to prevent exhaustion of the fund by random fluctuations.

In health care, an entity that assumes the risk of paying for medical treatments. This can be an uninsured patient, a self-insured employer, a health plan, or an HMO.

CMS's term for their pre-HIPAA National Payer ID initiative.

Costs incurred for processing of data.

The total payment that a hospital or community mental health center gets when they give outpatient services to Medicare patients.

Activities to prevent and recover inappropriate Medicare benefit payments including MSP, MR/UR, provider audits, and fraud and abuse detection.

See Suspension of Payments.

Taxes levied on the gross wages of workers.

An exam to check if internal female organs are normal by feeling their shape and size.

A number that corresponds to one of the equal divisions of the range of a variable in a given sample and that characterizes a value of the variable as not exceeded by a specified percentage of all the values in the sample. For example, a score higher that 97 percent of those attained is said to be in the 97th percentile.

The way in which an individual, group, or organization carries out or accomplishes its important functions or processes.

Involves the analysis and interpretation of performance measurement data to transform it into useful information for purposes of continuous performance improvement.

Projects that examine and seek to achieve improvement in major areas of clinical and non-clinical services. These projects are usually based on information such as enrollee characteristics, standardized measures, utilization, diagnosis and outcome information, data from surveys, grievance and appeals processes, etc. They measure performance at two periods of time to ascertain if improvement has occurred. These projects are required by the State and can be of the MCO/PHPs choosing or prescribed by the State.

Is information that shows how well a health plan provides a certain treatment, test, or other health care service to its members. For example, Medicare uses performance measures from NCQA?s Health Plan Employer Data and Information Set (HEDIS�) to get information on how well health plans perform in quality, how easy it is to get care, and members? satisfaction with the health plan and its doctors.

A gauge used to assess the performance of a process or function of any organization.
Quantitative or qualitative measures of the care and services delivered to enrollees (process) or the end result of that care and services (outcomes). Performance measures can be used to assess other aspects of an individual or organization's performance such as access and availability of care, utilization of care, health plan stability, beneficiary characteristics, and other structural and operational aspect of health care services. Performance measures included here may include measures calculated by the State (from encounter data or another data source), or measures submitted by the MCO/PHP.

A set period of time that you can get hospice care after your doctor says that you are eligible and still need hospice care.

A procedure that introduces dialysate into the abdominal cavity to remove waste products through the peritoneum (a membrane which surrounds the intestines and other organs in the abdominal cavity). It functions in a manner similar to that of the artificial semi permeable membrane in the hemodialysis machine. Three forms of peritoneal dialysis are continuous ambulatory peritoneal dialysis, continuous cycling peritoneal dialysis, and intermittent peritoneal dialysis.

PD uses a cleaning solution, called dialysate, that flows through a special tube into your abdomen. After a few hours, the dialysate gets drained from your abdomen, taking the wastes from your blood with it. Then you fill your abdomen with fresh dialysate and the cleaning process begins again. This treatment can be done at home, at your workplace, or at another convenient location (See dialysis and hemodialysis.).

Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in and out of bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops. The Medicare home health benefit does pay for personal care services.

Treatment of injury and disease by mechanical means, such as heat, light, exercise, and massage.

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.

A partnership, association, corporation, individual practice association (IPA), or other group that distributes income from the practice among members. An IPA is considered to be a physician group only if it is composed of individual physicians and has no subcontracts with other physician groups.

Any compensation arrangement at any contracting level between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to Medicare or Medicaid enrollees in the MCO. MCOs must disclose physician incentive plans between the MCO itself and individual physicians and groups and, also, between groups or intermediate entities (e.g., certain IPAs, Physician-Hospital Organizations) and individual physicians and groups. See 42 C.F.R. � 422.208(a).

Services provided by an individual licensed under state law to practice medicine or osteopathy. Physician services given while in the hospital that appear on the hospital bill are not included.

See National Payer ID.

Your doctor's written plan saying what kind of services and care you need for your health problem.

An entity that sponsors a health plan. This can be an employer, a union, or some other entity.

An additional, mandatory supplemental, or optional supplemental benefit that allows the enrollee the option of receiving specified services outside of the plan's provider network.

A Medicare Managed Care Plan option that lets you use doctors and hospitals outside the plan for an additional cost.

A generic name for many work groups at WEDI and elsewhere.

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

A case developed after the PSC has substantiated an allegation of fraud.

Means the maximum anticipated total payments (based on the most recent year's utilization and experience and any current or anticipated factors that may affect payment amounts) that could be received if use or costs of referral services were low enough. These payments include amounts paid for services furnished or referred by the physician/group, plus amounts paid for administrative costs. The only payments not included in potential payments are bonuses or other compensation not based on referrals (e.g., bonuses based on patient satisfaction or other quality of care factors).

A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a health care proxy, appointment of health care agent or a durable power of attorney for health care.

A health problem you had before the date that a new insurance policy starts.

An M+CO coordinated care plan that: (a) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (b) provides for reimbursement for all covered benefits regardless of whether the benefits are provided with the network of providers; and (c) is offered by an organization that is not licensed or organized under State law as an HMO. See Social Security Act Section 1852(e)(2)(D), 42 U.S.C. �139w-22(e)(2)(D).

A managed care in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

A type of Medicare Advantage Plan in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

The standard Medicare Part B premium will go up ten percent for each full 12-month period (beginning with the first month after the end of your Initial Enrollment Period) that you could have had Medicare Part B but didn?t take it. The additional premium amount is called a ?premium surcharge.? There will be a surcharge for Part D also.

A prepaid managed care entity that provides less than comprehensive services on an at risk basis or one that provides any benefit package on a non-risk basis.

The review of claims prior to determination and payment.

The present value of a future stream of payments is the lump-sum amount that, if invested today, together with interest earnings would be just enough to meet each of the payments as it fell due. At the time of the last payment, the invested fund would be exactly zero.

The number of existing cases of a disease or condition in a given population at a specific time.

Health care to keep you healthy or to prevent illness (for example, Pap tests, pelvic exams, flu shots, and screening mammograms).

Software modules in Medicare claims processing systems, specific to certain benefits, used in pricing claims, most often under prospective payment systems.

A person, an organization, or a software package that reviews procedures, diagnoses, fee schedules, and other data and determines the eligible amount for a given health care service or supply. Additional criteria can then be applied to determine the actual allowance, or payment, amount.

A basic level of care usually given by doctors who work with general and family medicine, internal medicine (internists), pregnant women (obstetricians), and children (pediatricians). A nurse practitioner (NP), a State licensed registered nurse with special training, can also provide this basic level of health care.

A PCCM provider is a provider (usually a physician, physician group practice, or an entity employing or having other arrangements with such physicians, but sometimes also including nurse practitioners, nurse midwives, or physician assistants) who contracts to locate, coordinate, and monitor covered primary care (and sometimes additional services). This category includes any PCCMs and those PHPs which act as PCCMs.

A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare managed care plans, you must see your primary care doctor before you see any other health care provider.

A program where the State contracts directly with primary care providers who agree to be responsible for the provision and/or coordination of medical services to Medicaid recipients under their care. Currently, most PCCM programs pay the primary care physician a monthly case management fee in addition to reimbursing services on a fee-for-service basis.

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

Without the written consent of the individual, the Privacy Act prohibits release of protected information maintained in a system of records unless of 1 of the 12 disclosure provisions applies.

A contract between you and a doctor, podiatrist, dentist, or optometrist who has decided not to offer services through the Medicare program. This doctor can?t bill Medicare for any service or supplies given to you and all his/her other Medicare patients for at least 2 years. There are no limits on what you can be charged for services under a private contract. You must pay the full amount of the bill.

A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan?s payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn?t cover.

Something done to fix a health problem or to learn more about it. For example, surgery, tests, and putting in an IV (intravenous line) are procedures.

The goal-directed, interrelated series of actions, events, mechanisms, or steps.

A methodology utilized to make improvements to a process through the use of continuous quality improvement methods.

A gauge that measures a goal-directed interrelated series of actions, events, mechanisms, or steps.

Spending aimed at increasing contractor operational efficiency and productivity through improved work methods, application of technology, etc.

Data segregated by specific time period (e.g. quarterly, annually) and target area (e.g. facility, State) for the purpose of identifying patterns.

CMS operational account. Program Management supplies the agency with the resources to administer Medicare, the Federal portion of Medicaid, and other Agency responsibilities. The components of Program Management are Medicare contractors, survey and certification, research, and administrative costs.

An automated system of records that contains records primarily of current Medicare-eligible ESRD patients, but also maintains historical information on people no longer classified as ESRD patients because of death or successful transplantation or recovery of renal function. The PMMIS contains medical information on patients and the services that they received during the course of their therapy. In addition, it contains information on ESRD facilities and facility payment. Beginning January 1, 1995, the PMMIS collects information on all dialysis and kidney transplant patients.

A contractor hired under this SOW.

PACE combines medical, social, and long-term care services for frail people. PACE is available only in states that have chosen to offer it under Medicaid. To be eligible, you must:

• Be 55 years old, or older,
• Live in the service area of the PACE program,
• Be certified as eligible for nursing home care by the appropriate state agency , and
• Be able to live safely in the community.

The goal of PACE is to help people stay independent and live in their community as long as possible, while getting high quality care they need.

An appointed person who is responsible overall for a project. A
departmental person is usually appointed.

Degree of variation between estimated and actual amounts.

The good and bad parts of treatment for a health problem. For example, a medicine may help your pain (pro), but it may cause an upset stomach (con).

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).

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.

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.

The providers with which an M+C Organization contracts or makes arrangements to furnish covered health care services to Medicare enrollees under an M+C coordinated care or network MSA plan.

A group of doctors, hospitals, and other health care providers that agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. This type of managed care plan is run by the doctors and providers themselves, and not by an insurance company. (See Managed Care Plan.)

Data collected through a survey or focus group of providers who participate in the Medicaid program and have provided services to enrolled Medicaid beneficiaries. The State or a contractor of the State may conduct the survey.

An administrative code set for identifying the provider type and area of specialization for all health care providers. A given provider can have several Provider Taxonomy Codes. This code set is used in the X12 278 Referral Certification and Authorization and the X12 837 Claim transactions, and is maintained by the NUCC.

An index of known values that likely approximates an index for which values are unavailable. The proxy is used as a "stand-in" for the unavailable index.

A facility for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

Partial hospitalization (location 52)�is a program in which a patient attends for several hours during the day (example: 8:30-3:30) the patient is not there on a 24 hours basis.

A facility or distinct part of a facility for psychiatric care that provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.

Non-identifiable data that is within the public domain.

A type of payment between two Federal agencies.