Glossary

A description of the circumstances in which certain data is required.

Under HIPAA, this is all the data elements and code sets inherent to a transaction, and not related to the format of the transaction.

A coordinating body within HHS that has high-level responsibility for overseeing the implementation of the A/S provisions of HIPAA.

A document or system that characterizes the data content of a system.

Under HIPAA, this is the smallest named unit of information in a transaction.

A form that is required for access to the DESY system. This system replaces
the Data Support Access Facility (DSAF).

A body that provides administrative services to X12 and several other standards-related groups.

The process of matching one set of data elements or individual code values to their closest equivalents in another set of them. This is sometimes called a cross-walk.

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

A form that is required for access to Leg 1 (Enrollment Database (EDB)) and,
Leg 2 (Medicare Provider Analysis and Review(MEDPAR)) of the Data Support Access Facility.

Legal binding agreement which CMS requires to obtain identifiable data.� It also delineates the confidentiality requirements of the Privacy Act of 1974 security safeguards, and CMS's data use policy and procedures.

A form used to provide pertinent information about the data request and
identifies the identifiable data being processed.

The day of the mailing (as evidenced by the postmark) or hand-delivery of materials, unless otherwise defined.

The date on the return receipt of "return receipt requested" mail, unless otherwise defined.

Subset of the HCPCS Level II medical codes identifying certain dental procedures. It replicates many of the CDT codes and will be replaced by the CDT. Descriptor: The text defining a code in a code set.

The amount you must pay for health care before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B. These amounts can change every year. (See Benefit Period; Medicare Part A; Medicare Part B.)

Providers are ?deemed? when they know, before providing services, that you are in a Private Fee-for-Service Plan, and they agree to give you care. Providers that are ?deemed? agree to follow your plan?s terms and conditions of payment for the services you get.

Designation that an M+C organization has been reviewed and determined "fully accredited" by a HCFA-approved accrediting organization for those standards within the deeming categories that the accrediting organization has the authority to deem.

See "Non-contributory or deemed wage credits."

The authority granted by CMS to accrediting organizations to determine, on CMS's behalf, whether a M+CO evaluated by the accrediting organization is in compliance with corresponding Medicare regulations.

A finding that a nursing home failed to meet one or more federal or state requirements.

A serious condition where your body's loss of fluid is more than your body's intake of fluid.

See Assumptions.

Data that describe the characteristics of enrollee populations within a managed care entity. Demographic data include but are not limited to age, sex, race/ethnicity, and primary language.

Projects and contracts that CMS has signed with various health care organizations. These contracts allow CMS to test various or specific attributes such as payment methodologies, preventive care, social care, etc., and to determine if such projects/pilots should be continued or expanded to meet the health care needs of the Nation. Demonstrations are used to evaluate the effects and impact of various health care initiatives and the cost implications to the public.

An organization, hosted by the American Dental Association, that maintains the data content specifications for dental billing. The Dental Content Committee has a formal consultative role under HIPAA for all transactions affecting dental health care 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.)

A subset from an original identifiable file.

The text defining a code in a code set.

A medical code set or an administrative code set that is required to be used by the adopted implementation specification for a standard transaction.

An organization which HHS has designated for oversight of the business data content of one or more of the HIPAA-mandated transaction standards.

A standard which HHS has designated for use under the authority provided by HIPAA.

An organization, designated by the Secretary of the U.S. Department of Health & Human Services, to maintain standards adopted under Subpart I of 45 CFR Part 162. A DSMO may receive and process requests for adopting a new standard or modifying an adopted standard.

A decision made to either pay in full, pay in part, or deny a claim. (See also Initial Claim Determination.)

Purchased or rented ambulatory items, such a glucose meters and insulin infusion pumps, prescribed by a�health care provider for use in managing a patient's diabetes, as covered by Medicare.

The name for the health problem that you have.

The first of these codes is the ICD-9-CM diagnosis code describing the principal diagnosis (i.e. The condition established after study to be chiefly responsible for causing this hospitalization). The remaining codes are the ICD-9-CM diagnosis codes corresponding to additional conditions that coexisted at the time of admission, or developed subsequently, and which had an effect on the treatment received or the length of stay.

A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual.

Dialysate or the dialysate fluid is the solution used in dialysis to remove excess fluids and waste products from the blood.

A process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semi-permeable membrane. The two types of dialysis that are currently commonly in use are hemodialysis and peritoneal dialysis.

Dialysis is a treatment that cleans your blood when your kidneys don?t work. It gets rid of harmful wastes and extra salt and fluids that build up in your body. It also helps control blood pressure and helps your body keep the right amount of fluids. Dialysis treatments help you feel better and live longer, but they are not a cure for permanent kidney failure (See hemodialysis and peritoneal dialysis.).

A hospital unit that is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of the ESRD dialysis patients (including inpatient dialysis) furnished directly or under arrangement.

A unit (hospital based or freestanding) which is approved to furnish dialysis services directly to ESRD patients.

A portion of the dialysis patient treatment area which accommodates the equipment necessary to provide a hemodialysis or peritoneal dialysis treatment. This station must have sufficient area to house a chair or bed, the dialysis equipment, and emergency equipment if needed. Provision for privacy is ordinarily supplied by drapes or screens.

A drug given to pregnant women from the early 1940s until 1971 to help with common problems during pregnancy. The drug has been linked to cancer of the cervix or vagina in women whose mother took the drug while pregnant.

A standard for communicating images, such as x-rays, in a digitized form. This standard could become part of the HIPAA claim attachments standards.

Under HIPAA, this is the direct entry of data that is immediately transmitted into a health plan's computer.

For Social Security purposes, the inability to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or to last for a continuous period of not less than 12 months. Special rules apply for workers aged 55 or older whose disability is based on blindness. The law generally requires that a person be disabled continuously for 5 months before he or she can qualify for a disabled worker cash benefit. An additional 24 months is necessary to qualify under Medicare.

See "Old-Age, Survivors, and Disability Insurance (OASDI)."

An individual under age 65 who has been entitled to disability benefits under Title II of the Social Security Act or the Railroad Retirement system for at least 2 years and who is enrolled in the SMI program.

A process used to decide what a patient needs for a smooth move from one level of care to another. This is done by a social worker or other health care professional. It includes moves from a hospital to a nursing home or to home care. Discharge planning may also include the services of home health agencies to help with the patient's home care.

Release or divulgence of information by an entity to persons or organizations outside of that entity.

Under HIPAA this is a list of any entities that have received personally identifiable health care information for uses unrelated to treatment and payment.

A list of certain drugs and their proper dosages. The discount drug list includes the drugs the company will discount.

Outlays of funds subject to the Federal appropriations process.

Ending your health care coverage with a health plan.

A hospital with a disproportionately large share of low-income patients. Under Medicaid, States augment payment to these hospitals. Medicare inpatient hospital payments are also adjusted for this added burden.

Reduce the value and code of a claim when the documentation does not support the level of service billed by a provider.

An archaic term for any X12 standard that has been approved since the most recent release of X12 American National Standards. The current equivalent term is "X12 standard".

The DRG categories used by hospitals on discharge billing. See also "Diagnosis-related groups (DRGs)."

Drug tiers are definable by the plan. The option �tier� was introduced in the PBP to allow plans the ability to group different drug types together (i.e., Generic, Brand, Preferred Brand). In this regard, tiers could be used to describe drug groups that are based on classes of drugs. If the �tier� option is utilized, plans should provide further clarification on the drug type(s) covered under the tier in the PBP notes section(s). This option was designed to afford users additional flexibility in defining the prescription drug benefit.

Persons who are entitled to Medicare (Part A and/or Part B) and who are also eligible for Medicaid.

Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs, and other medically necessary equipment prescribed by a health care provider to be used in a patient's home which are covered by Medicare.

Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.

Medical equipment that is ordered by a doctor (or, if Medicare allows, a nurse practitioner, physician assistant or clinical nurse specialist) for use in the home. A hospital or nursing home that mostly provides skilled care can?t qualify as a ?home? in this situation. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.

A private company that contracts with Medicare to pay bills for durable medical equipment.

A legal document that enables you to designate another person, called the attorney-in-fact, to act on your behalf, in the event you become disabled or incapacitated.