Glossary

International Classification of Diseases, with "n" = "9" for Revision 9 or "10" for Revision 10, with "CM" = "Clinical Modification", and with "PCS" = "Procedure Coding System".

Transplant drugs used to reduce the risk of rejecting the new kidney after transplant. Transplant patients will need to take these drugs for the rest of their lives.

A document explaining the proper use of a standard for a specific business purpose. The X12N HIPAA IGs are the primary reference documents used by those implementing the associated transactions, and are incorporated into the HIPAA regulations by reference.

Under HIPAA, this is the specific instructions for implementing a standard.

A plan for measurable process or outcome improvement. The plan is usually developed cooperatively by a provider and the Network. The plan must address how and when its results will be measured.

Utilization of services that are in excess of a beneficiary's medical needs and condition (overutilization) or receiving a capitated Medicare payment and failing to provide services to meet a beneficiary's medical needs and condition (underutilization).

The frequency of new occurrences of a condition within a defined time interval. The incidence rate is the number of new cases of specific disease divided by the number of people in a population over a specified period of time, usually one year.

The ratio of income from tax revenues on an incurred basis (payroll tax contributions and income from the taxation of OASDI benefits) to the HI taxable payroll for the year.

The costs based on when the service was performed rather than when the payment was made.

A freestanding clinical laboratory meeting conditions for participation in the Medicare program and billing through a carrier.
A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.

A key clinical value or quality characteristic used to measure, over time, the performance, processes, and outcomes of an organization or some component of health care delivery.

A conceptual model of the information needed to support a business function or process.

(See State Health Insurance Assistance Program.)

Pumps for giving fluid or medication into your vein at a specific rate or over a set amount of time.

The first adjudication made by a carrier or fiscal intermediary (FI) (i.e., the affiliated contractor) following a request for Medicare payment or the first determination made by a PRO either in a prepayment or postpayment context.

The 3 months immediately before you are entitled to Medicare Part A and enrolled in Part B. You may choose a Medicare health plan during your Initial Coverage Election Period. The plan must accept you unless it has reached its limit in the number of members. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP). (See Election Periods; Enrollment/Part A; Initial Enrollment Period (IEP).)

The Initial Enrollment Period is the first chance you have to enroll in Medicare Part B. Your Initial Enrollment Period starts three months before you first meet all the eligibility requirements for Medicare and lasts for seven months.

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.

Health care that you get when you are admitted to a hospital.

A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services by or under the supervision of physicians, to patients admitted for a variety of medical conditions.

An amount of money that is deducted from the amount payable by Medicare Part A for inpatient hospital services furnished to a beneficiary during a spell of illness.

These services include bed and board, nursing services, diagnostic or therapeutic services, and medical or surgical services.

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

When a health plan has no money or other means to stay open and give health care to patients.

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.

A written contract in which the Federal agency agrees to provide to, purchase
from, or exchange with another Federal agency, services (including data),
supplies or equipment. Inter-agency agreements are between at least one
component with DHHS and another Federal agency or component thereof.
Intra-agency agreements are between two or more agencies within
DHHS.

A payment for the use of money during a specified period.

The borrowing of assets by a trust fund (OASI, DI, HI, or SMI) from another of the trust funds when one of the funds is in danger of exhaustion. Interfund borrowing was authorized only during 1982-1987.

A private company that has a contract with Medicare to pay Part A and some Part B bills.

That hearing provided for in 42 CFR �405.1809.

A determination as defined in 42 CFR �405.1801 under the definition for Intermediary Determination.

See "Assumptions."

A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care available in a hospital or skilled nursing facility.

These are entities, which contract between an MCO or one of its subcontractors and a physician or physician group, other than physician groups themselves. An IPA is considered to be an intermediate entity if it contracts with one or more physician groups in addition to contracting with individual physicians.

An intermittent (periodic), supine regimen, which uses intermittent flow technique, automated assisted manual, or manual method in dialysis sessions two to four times weekly.

Management systems and policies for reasonably documenting, monitoring, and correcting operational processes to prevent and detect waste and to ensure proper payment.

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.

A medical code set maintained by the World Health Organization (WHO). The primary purpose of this code set was to classify causes of death. A US extension, maintained by the NCHS within the CDC, identifies morbidity factors, or diagnoses. The ICD-9-CM codes have been selected for use in the HIPAA transactions.

An organization that coordinates the development and adoption of numerous international standards. "ISO" is not an acronym, but the Greek word for "equal".

A doctor who finds and treats health problems in adults.

Assets or liabilities that arise from transactions among federal entities.