Glossary

Budgeted funds committed to be spent.

Services given to help you return to usual activities (such as bathing, preparing meals, housekeeping) after illness.

Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

This office is part of HHS. Its HIPPA responsibilities include oversight of the privacy requirements.

A Federal Government agency that has a major role in reviewing proposed Federal regulations.

The recovery by Medicare of a non-Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness. (Examples are Public Health Service debts or Medicaid debts recovered by CMS). (See also Recoupment and Suspension of Payments.)

The Social Security programs that pay for (1) monthly cash benefits to retired-worker (old-age) beneficiaries, their spouses and children, and survivors of deceased insured workers (OASI); and (2) monthly cash benefits to disabled-worker beneficiaries and their spouses and children, and for providing rehabilitation services to the disabled (DI).

An ombudsman is an individual who assists enrollees in resolving problems they may have with their MCO/PHP. An ombudsman is a neutral party who works with the enrollee, the MCO/PHP, and the provider (as appropriate) to resolve individual enrollee problems.

An advocate (supporter) who works to solve problems between residents and nursing homes, as well as assisted living facilities. Also called "Long-term Care Ombudsman."

Reviews performed on-site at the MCO/PHP health care delivery system sites to assess the physical resources and operational practices in place to deliver health care.

A one-time-only six month period when you can buy any Medigap policy you want that is sold in your State. It starts in the first month that you are covered under Medicare Part B and you are age 65 or older. During this period, you can?t be denied coverage or charged more due to past or present health problems.

A multi-layer ISO data communications standard. Level Seven of this standard is industry-specific, and HL7 is responsible for specifying the level seven OSI standards for the health industry.

Services not covered by Medicare that enrollees can choose to buy or reject. Enrollees that choose such benefits pay for them directly, usually in the form of premiums and/or cost sharing. Those services can be grouped or offered individually and can be different for each M+C plan offered.

Organ means a human kidney, liver, heart, or pancreas.

The process of acquiring donor kidneys in the ESRD program.

An organization that performs or coordinates the retrieval, preservation, and transportation of organs and maintains a system of locating prospective recipients for available organs.

A health plan's decision on whether to pay all or part of a bill, or to give medical services, after you file an appeal. If the decision is not in your favor, the plan must give you a written notice. This notice must give a reason for the denial and a description of steps in the appeals process. (See Appeals Process.)

A pay-per-visit health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Other Managed Care Arrangement is used if the plan is not considered either a PCCM, PHP, Comprehensive MCO, Medicaid-only MCO, or HIO.

Other service facilities not previously identified.

Services provided to enrollees by providers that have no contractual or other relationship with M+C Organizations.

Generally, an out-of-network benefit provides a beneficiary with the option to access plan services outside of the plan?s contracted network of providers. In some cases, a beneficiary?s out-of-pocket costs may be higher for an out-of-network benefit.

The result of performance (or nonperformance) of a function or process.

A group of data elements that represent core items of a comprehensive
assessment for an adult home care patient and form the basis for measuring
patient outcomes for purposes of outcome-based quality improvement (OBQI).
This assessment is performed on every patient receiving services of Home Health agencies that are approved to participate in the Medicare and/or Medicaid programs.

Data that measure the health status of people enrolled in managed care resulting from specific medical and health interventions (e.g. the incident of measles among plan enrollees during the calendar year).

An indicator that assesses what happens or does not happen to a patient following a process; agreed upon desired patient characteristics to be achieved; undesired patient conditions to be avoided.

The issuance of checks, disbursement of cash, or electronic transfer of funds made to liquidate an expense regardless of the fiscal year the service was provided or the expense was incurred. When used in the discussion of the Medicaid program, outlays refer to amounts advanced to the States for Medicaid benefits.

Additions to a full episode payment in cases where costs of services delivered are estimated exceed a fixed loss threshold. HH PPS outliers are computed as part of Medicare claims payment by Pricer Software.

Health care costs that you must pay on your own because they are not covered by Medicare or other insurance.

Medical or surgical care that does not include an overnight hospital stay.

A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
Part of the Hospital providing services covered by SMI, including services in an emergency room or outpatient clinic, ambulatory surgical procedures, medical supplies such as splints, laboratory tests billed by the hospital, etc.

Medicare or surgical care that Medicare Part B helps pay for and does not include an overnight hospital stay, including:

• blood transfusions;
• certain drugs;
• hospital billed laboratory tests;
• mental health care;
• medical supplies such as splints and casts;
• emergency room or outpatient clinic, including same day surgery; and
• emergency room or outpatient clinic, including same day surgery; and
• x-rays and other radiation services.

The way that Medicare pays for most outpatient services at hospitals or community mental health centers under Medicare Part B.

A service you get in one day (24 hours) at a hospital outpatient department or community mental health center.

A decision that an incorrect amount of money has been paid for Medicare services and a determination of what that amount is.