Glossary

The surgical procedure of excising a kidney from a deceased individual and implanting it into a suitable recipient.

Subject to redemption upon notice, as is a bond.

A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member's health care services for a certain length of time.

Durable medical equipment (like nebulizers or manual wheelchairs) that costs more than $150, and the supplier rents it to people with Medicare more than 25 percent of the time.

A written plan for your care. It tells what services you will get to reach and keep your best physical, mental, and social well being.

A person who helps care for someone who is ill, disabled, or aged. Some caregivers are relatives or friends who volunteer their help. Some people provide caregiving services for a cost.

A private company that has a contract with Medicare to pay your Medicare Part B bills. (See Medicare Part B.)

A process used by a doctor, nurse, or other health professional to manage your health care. Case managers make sure that you get needed services, and track your use of facilities and resources.

A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.

Is the distribution of patients into categories reflecting differences in severity of illness or resource consumption.

The average DRG relative weight for all Medicare admissions.

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

A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause you financial hardship.

The highest amount of money you have to pay out of your pocket during a certain period of time for certain covered charges. Setting a maximum amount you will have to pay protects you.

A health information technology industry association.

An organization that maintains several code sets included in the HIPAA standards, including the ICD-9-CM codes.

The HHS agency responsible for Medicare and parts of Medicaid.�Centers for Medicare & Medicaid Services has historically maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.

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.

A form that is required for access to the CMS data center.

A short-term certificate of ownership (12 months or less) of a specified portion of a debt due by the federal government to individual holders, bearing a fixed rate of interest.

A form required by Medicare that allows you to use certain durable medical equipment prescribed by your doctor or one of the doctor?s office staff.

This means a hospital has passed a survey done by a State government agency. Being certified is not the same as being accredited. Medicare only covers care in hospitals that are certified or accredited.

CNAs are trained and certified to help nurses by providing non-medical assistance to patients, such as help with bathing, dressing, and using the bathroom.

A nurse who is trained and licensed to give anesthesia. Anesthesia is given before and during surgery so that a person does not feel pain. (See Anesthesia.)

A term used in the HIPAA Security NPRM for a pattern of agreements that extend protection of health care data by requiring that each covered entity that shares health care data with another entity require that that entity provide protections comparable to those provided by the covered entity, and that that entity, in turn, require that any other entities with which it shares the data satisfy the same requirements.

Contract needed to extend the responsibility to protect health care data across a series of sub-contractual relationships.

Dialysis that is regularly furnished to an ESRD patient in a hospital based independent (non-hospital based), or home setting.

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")

A claim is a request for payment for services and benefits you received. Claims are also called bills for all Part A and Part B services billed through Fiscal Intermediaries. "Claim" is the word used for Part B physician/supplier services billed through the Carrier. (See Carrier; Fiscal Intermediaries; Medicare Part A; Medicare Part B.)

A national administrative code set that identifies the reasons for any differences, or adjustments, between the original provider charge for a claim or service and the payer's payment for it. This code set is used in the X12 835 Claim Payment & Remittance Advice and the X12 837 Claim transactions, and is maintained by the Health Care Code Maintenance Committee.

Any of a variety of hardcopy forms or electronic records needed to process a claim in addition to the claim itself.

A national administrative code set that indicates the general category of the status of health care claims. This code set is used in the X12 277 Claim Status Notification transaction, and is maintained by the Health Care Code Maintenance Committee.

A national administrative code set that identifies the status of health care claims. This code set is used in the X12N 277 Claim Status Inquiry and Response transaction, and is maintained by the Health Care Code Maintenance Committee.

An exam by your doctor/health care provider to check for breast cancer by feeling and looking at your breasts. This exam is not the same as a mammogram and is usually done in the doctor's office during your Pap test and pelvic exam.

This is a method or instrument to estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality.

Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.

Clinical trials are one of the final stages of a long and careful research process to help patients live longer, healthier lives. They help doctors and researchers find better ways to prevent, diagnose, or treat diseases. Clinical trials test new types of medical care, like how well a new cancer drug works. The trials help doctors and researchers see if the new care works and if it is safe. They may also be used to compare different treatments for the same condition to see which treatment is better, or to test new uses for treatments already in use.

Any individual or organization, public or private, with whom CMS has a contractual arrangement to contribute to or participate in the Medicare survey and certification process. The State survey agency is the most common example of a "CMS" agent as established through the partnership role of the State agency (SA) plays in the survey process under the provisions of �1864 of the Act. A private physician serving a contractual consultant role with the SA or CMS regional office as part of a survey and certification activity is another example of a "CMS agent".

A CMS directed improvement project is any project where CMS specifies the subject, size, pace, data source, analytic techniques, educational intervention techniques, or impact measurement model. These projects may be developed by CMS in consultation with Networks, the health care community, and other interested people.

The uniform institutional claim form.

The uniform professional claim form.

The official compilation of federal rules and requirements.

Under HIPAA, this is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions. Also see Part II, 45 CFR 162.103.

Under HIPAA, this is an organization that creates and maintains the code sets adopted by the Secretary for use in the transactions for which standards are adopted. Also see Part II, 45 CFR 162.103.

A breakdown in a person's mental state that may affect a person's moods, fears, anxieties, and ability to think clearly.

A population group that shares a common property, characteristic, or event, such as a year of birth or year of marriage. The most common one is the birth cohort, a group of individuals born within a defined time period, usually a calendar year or a five-year interval.

The percentage of the Private Fee-for-Service Plan charge for services that you may have to pay after you pay any plan deductibles. In a Private Fee-for-Service Plan, the coinsurance payment is a percentage of the cost of the service (like 20%).

The percentage of the Medicare payment rate or a hospital's billed charge that you have to pay after you pay the deductible for Medicare Part B services.

A professional organization for health care Chief Information Officers (CIOs).

Public commentary on the merits or appropriateness of proposed or potential regulations provided in response to an NPRM, an NOI, or other federal regulatory notice.

A Commercial MCO is a health maintenance organization, an eligible organization with a contract under �1876 or a Medicare-Choice organization; a provider sponsored organization, or any other private or public organization, which meets the requirements of �1902(w). These MCOs provide comprehensive services to commercial and/or Medicare enrollees, as well as Medicaid enrollees.

A facility that provides the following services:

• Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharge from inpatient treatment at a mental health facility,
• 24 hour a day emergency care services,
• Day treatment, other than partial hospitalization services, or psychosocial rehabilitation services,
• Screening for patients considered for admission to State mental health facilities to determine the appropriateness of such admission, and
• Consultation and education services.

(See Grievance.)

A statement, oral or written, alleging that a provider or beneficiary received a Medicare benefit of monetary value, directly or indirectly, overtly or covertly, in cash or in kind, to which he or she is not entitled under current Medicare law, regulations, or policy. Included are allegations of misrepresentation and violations of Medicare requirements applicable to persons or entities that bill for covered items and services.

Under HIPAA, this is the date by which a covered entity must comply with a standard, an implementation specification, or a modification. This is usually 24 months after the effective data of the associated final rule for most entities, but 36 months after the effective data for small health plans. For future changes in the standards, the compliance date would be at least 180 days after the effective data, but can be longer for small health plans and for complex changes.

A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.

A MCO is a health maintenance organization, an eligible organization with a contract under �1876 or a Medicare-Choice organization; a provider sponsored organization or any other private or public organization, which meets the requirements of �1902(w). These MCOs provides comprehensive services to both commercial and/or Medicare, as well as Medicaid enrollees.

A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.

A facility that provides a variety of services including physicians' services, physical therapy, social or psychological services, and outpatient rehabilitation.

Any computerized comparison of two or more systems of records or a system of
records of non-Federal records for the purpose of (1) establishments or
verifying eligibility or compliance with law and regulations of applicants or
recipients/beneficiaries, or (2) recouping payments or overpayments.

An industry organization that promotes the use of healthcare information systems, including electronic healthcare records.

A payment made by Medicare for services for which another payer is responsible.

Your right to talk with your health care provider without anyone else finding out what you have said.

A covered entity may use or disclose PHI only:

• With the consent of the individual for treatment, payment, or health care operations;
• With the authorization of the individual for all other uses or disclosures;
• As permitted under this rule for certain public policy purposes.

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.

An annual nationwide survey that is used to report information on Medicare beneficiaries' experiences with managed care plans. The results are shared with Medicare beneficiaries and the public.

A measure of the average change in prices over time in a fixed group of goods and services. In this report, all references to the CPI relate to the CPI for Urban Wage Earners and Clerical Workers (CPI-W).

Data collected through survey or focus group. Surveys may include Medicaid beneficiaries currently or previously enrolled in a MCO or PHP. The survey may be conducted by the State or a contractor to the State.

Data collected through a survey of those Medicaid beneficiaries who are enrolled in the program and have used the services. The survey may be conducted by the State or by the managed care entity (if the managed care entity reports the results to the State).

Funds included in the trust fund to serve as a cushion in case actual expenditures are higher than those projected at the time financing was established. Since the financing is set prospectively, actual experience may be different from the estimates used in setting the financing.

An amount included in the actuarial rates to provide for changes in the contingency level in the trust fund. Positive margins increase the contingency level, and negative margins decrease it.

Allows MCOs to offer enrollees the option of continued enrollment in the M+C plan when enrollees leave the plan?s service area to reside elsewhere. CMS has interpreted this to be on a permanent basis. M+C Organizations that choose the continuation of enrollment option must explain it in marketing materials and make it available to all enrollees in the service area. Enrollees may choose to exercise this option when they move or they may choose to disenroll.

A housing community that provides different levels of care based on what each resident needs over time. This is sometimes called "life care" and can range from independent living in an apartment to assisted living to full-time care in a nursing home. Residents move from one setting to another based on their needs but continue to live as part of the community. Care in CCRCs is usually expensive. Generally, CCRCs require a large payment before you move in and charge monthly fees.

A type of dialysis where the patient's peritoneal membrane is used as the dialyzer. The patient dialyzes at home, using special supplies, but without the need for a machine (see peritoneal dialysis).

A type of dialysis where the patient generally dialyzes at home and utilizes an automated peritoneal cycler for delivering dialysis exchanges (see peritoneal dialysis).

A process which continually monitors program performance. When a quality problem is identified, CQI develops a revised approach to that problem and monitors implementation and success of the revised approach. The process includes involvement at all stages by all organizations, which are affected by the problem and/or involved in implementing the revised approach.

An entity that has an agreement with CMS or another funding agency to perform a project.

Policy developed by CMS Contractors (PSC, AC, FI, or carrier) and used to make coverage and coding determinations. It is developed when:

• there is an absence of national coverage policy for a service or all of the uses of a service;
• there is a need to interpret national coverage policy; or
• local coding rules are needed.

See "Maximum tax base."

See "Payroll taxes."

A plan that includes a CMS-approved network of providers that are under contract or arrangement with the M+C organization to deliver the benefit package approved by CMS. Coordinated care plans include plans offered by health maintenance organizations (HMOs), provider-sponsored organizations (PSOs), preferred provider organizations (PPOs), as well as other types of network plans (except network MSA plans. See 42 C.F.R. � 422.4(a)(1).

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.

Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called cross-over.

A period of time when your employer group health plan will pay first on your health care bills and Medicare will pay second. If your employer group health plan doesn't pay 100% of your health care bills during the coordination period, Medicare may pay the remaining costs.

The ratio of the cost (or outgo, expenditures, or disbursements) of the program on an incurred basis during a given year to the taxable payroll for the year. In this context, the outgo is defined to exclude benefit payments and administrative costs for those uninsured persons for whom payments are reimbursed from the general fund of the Treasury, and for voluntary enrollees, who pay a premium to be enrolled.

The report required from providers on an annual basis in order to make a proper determination of amounts payable under the Medicare program.

The cost for medical care that you pay yourself like a copayment, coinsurance, or deductible. (See Coinsurance; Copayment; Deductible.)

A type of managed care organization that will pay for all of the enrollees/members' medical care costs in return for a monthly premium, plus any applicable deductible or co-payment. The HMO will pay for all hospital costs (generally referred to as Part A) and physician costs (generally referred to as Part B) that it has arranged for and ordered. Like a health care prepayment plan (HCPP), except for out-of-area emergency services, if a Medicare member/enrollee chooses to obtain services that have not been arranged for by the HMO, he/she is liable for any applicable deductible and co-insurance amounts, with the balance to be paid by the regional Medicare intermediary and/or carrier.

CALs is an abbreviated process, similar to the NCD process, for making changes to the coding component of the negotiated laboratory NCDs. The process is used for adjusting the list of covered (or non-covered) ICD-9-CM diagnosis codes and coding guidance in the NCDs when there is a question regarding whether the code flows from the narrative indications in the NCD. A tracking sheet is posted opening a CAL and a 30-day public comment period follows. A decision memorandum announcing and explaining the decision is posted following the comment period. Changes are implemented in the next available quarterly update of the laboratory edit module. More details regarding the process can be found in 68 FR 74607.

The M+C Plan charge schedule used to base the maximum dollar coverage or coinsurance level for a service category (e.g., a $500 annual coverage limit for a prescription drug benefit may be based on a Published Retailed Price schedule, or 20% coinsurance for DME benefit may be based on a Medicare FFS fee schedule).

The CIM has been replaced by the Medicare National Coverage Determinations Manual.

A health service or item that is included in your health plan, and that is paid for either partially or fully.

Services or benefits for which a health plan makes either partial or full payment.

Earnings in employment covered by the HI program.

All employment and self-employment creditable for Social Security purposes. Almost every kind of employment and self-employment is covered under the program. In a few employment situations-for example, religious orders under a vow of poverty, foreign affiliates of American employers, or the employer must elect State and local governments-coverage. However, effective July 1991, coverage is mandatory for State and local employees who are not participating in a public employee retirement system. All new State and local employees have been covered since April 1986. In a few situations-for instance, ministers or self-employed members of certain religious groups-workers can opt out of coverage. Covered employment for HI includes all federal employees (whereas covered employment for OASDI includes some, but not all, federal employees).

Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Functions that make an entity a health plan, a health care provider, or a health care clearinghouse.

Services for which SMI pays, as defined and limited by statute. Covered services include most physician services, care in outpatient departments of hospitals, diagnostic tests, DME, ambulance services, and other health services that are not covered by the HI program.

A person who has earnings creditable for Social Security purposes on the basis of services for wages in covered employment and/or on the basis of income from covered self-employment. The number of HI covered workers is slightly larger than the number of OASDI covered workers because of different coverage status for federal employment. See "Covered employment."

Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period. (See Pre-existing Conditions.)

The expected levels of achievement or specifications against which performance can be assessed.

A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.

A new test is determined to be similar to an existing test, multiple existing test codes, or a portion of an existing test code. The new test code is then assigned the related existing local fee schedule amounts and resulting national limitation amount. In some instances, a test may only equate to a portion of a test, and, in those instances, payment at an appropriate percentage of the payment for the existing test is assigned.

A medical code set of dental procedures, maintained and copyrighted by the American Dental Association (ADA), and adopted by the Secretary of HHS as the standard for reporting dental services on standard transactions.

A medical code set of physician and other services, maintained and copyrighted by the American Medical Association (AMA), and adopted by the Secretary of HHS as the standard for reporting physician and other services on standard transactions.

Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving round, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn?t pay for custodial care.

A facility, which provides room, board, and other personal assistance services, generally on a long-term basis and which does not include a medical component.

The person responsible for the security and safeguard of CMS data for the duration of the project.