Glossary of Terms and Acronyms

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Accessibility of Services
Your ability to get medical care and services when you need them.

Accessory Dwelling Unit (ADU)
A separate housing arrangement within a single-family home. The ADU is a complete living unit and includes a private kitchen and bath.

Accommodation
A type of hospital room, e.g., private, semiprivate, ward, etc.

Activities of Daily Living (ADL)
Personal tasks which are ordinarily performed on a daily basis and include eating, mobility/transfer, dressing, bathing, toileting and grooming.

ACS
Alternative Community Services

ACES
Arkansas Client Eligibility System

Adjudicate
To determine whether a claim is to be paid or denied.

Adjustments
Transactions to correct claims paid in error or to adjust payments from a retroactive change.

ADL
Activities of Daily Living

Admission
Actual entry and continuous stay of the recipient as an inpatient to an institutional facility.

Advance Beneficiary Notice (ABN)
A notice that a doctor or supplier should give a Medicare beneficiary to sign in the following cases:

• Your doctor gives you a service that he or she knows or believes that Medicare does not consider medically necessary; and
• Your doctor gives you a service that he or she knows or believes that Medicare will not pay for.
  If you do not get an ABN to sign before you get the service from your doctor, and Medicare does not pay for it, then you are not responsible for paying for that service. If the doctor does give you an ABN, which you agree to sign before you get the service, and Medicare does not pay for it, then you will have to pay your doctor for the service. ABN only applies if you are in the Original Medicare Plan. It does not apply if you are in a Medicare managed care plan. (See definition of the Original Medicare Plan.)

Advance Directives
Your written statement, also called a Living Will, that tells others how you would like to receive health care, including routine treatments and life-saving methods, if you are unable to do so. You can also choose someone to act on your behalf to make medical decisions if you are unable to do so.

AEVCS
Automated Eligibility Verification and Claims Submission

AFDC
Aid to Families with Dependent Children

AFMC
Arkansas Foundation for Medical Care, Inc. Quality Improvement Organization (QIO) for Arkansas

Affiliates
Persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another.

Affiliated Provider
A health care provider or facility that is paid by a health plan to give services to health plan members.
Aid Category
A designation within SSI or state regulations under which a person may be eligible for public assistance.

AHA
Arkansas Hospital Association

AHQA
American Healthcare Quality Association

Aid to Families with Dependent Children (AFDC)
A Medicaid eligibility category.

Allowed Amount
The maximum amount Medicaid will pay for a service as billed before applying recipient coinsurance or copay, previous TPL payment, spend down liability or other deducted charges.

AMA
American Medical Association
National association of physicians.

Ambulatory Care
All types of health services that do not require an overnight hospital stay.

Ambulatory Surgical Center
A free standing facility or separate part of a hospital that does outpatient surgery.

AMI
Acute Myocardial Infarction

Ancillary Services
Services available to a patient other than room and board. For example: pharmacy, X-ray, lab and central supplies.

Arkansas Client Eligibility System (ACES)
A state computer system in which data is entered to update assistance eligibility information and recipient files.

Attending Physician
See Performing Physician.

Automated Eligibility Verification Claims Submission (AEVCS)
On-line system for providers to verify eligibility of recipients and submit claims to fiscal agent.

Appeals Process
The process you use if you disagree with any decision about your health care services. If Medicare does not pay for an item or service you have been given, or if you are not given a service you think you should get, you can have the initial Medicare decision reviewed again. If you are in the Original Medicare Plan, your appeal rights are on the back of the Explanation of Medicare Benefits (EOMB) or Medicare Summary Notice (MSN) that is mailed to you from a company that handles bills for Medicare. If you are in a Medicare managed care plan, you can file an appeal if your plan will not pay for, does not allow, or stops a service that you think should be covered or provided. The Medicare managed care plan must tell you in writing how to appeal. See your plan's membership materials or contact your plan for details about your Medicare appeal rights. (See also Organization Determination.)

Approved Amount
The fee Medicare sets as reasonable for a medical service covered under Medicare Part B (Medical Insurance). It may be less than the actual amount charged. Approved Amount is sometimes also called “Approved Charge.” (See Actual Charge, Assignment.)

Area Agencies on Aging (AAA)
Local government agencies, which contract with public and private organizations to provide services for seniors within their area.

Assessment
The rating of your health status and care needs done by staff in a hospital, nursing home, home care agencies, or other health care settings.

Assignment
In the Original Medicare Plan, a process through which a doctor or supplier agrees to accept the amount of money Medicare approves for their fees as payment in full. You must pay any coinsurance amount. (See Actual Charge; Approved Amount.)

Assisted living
A type of living arrangement where personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility. In most cases, the "assisted living" residents pay a regular monthly rent. They typically pay additional fees for the services they get.

Base Charge
A set amount allowed for a participating provider according to specialty.

Beneficiary
The name for a person who has health care insurance through the Medicare or Medicaid Program.

Benefits
The money or services offered to a beneficiary by an insurance policy. In Medicare or a health plan, benefits take the form of health care.

Billed Amount
The amount billed to Medicaid for a rendered service.

Board and care home
A type of group living arrangement designed to meet the needs of people who cannot live on their own. These homes offer help with some personal care services.

Buy-In
A process whereby the state enters into an agreement with the Bureau of Health Insurance, Social Security Administration, to obtain supplementary medical insurance benefits (Medicare, Part A or B) for eligible recipients. The state pays the monthly premium on behalf of the recipient.

Care Plan
See Plan of Care (POC)

Casehead
An adult responsible for an AFDC or Medicaid child.

Case Management
A process used by a doctor, nurse, or other health care professional to manage your care and health-related matters. Case management makes sure that needed services are given, and keeps track of the use of facilities and resources.

Categorically Needy
All individuals receiving financial assistance under the state’s approved plan under Title I, IV-A, X, XIV and XVI of the Social Security Act or in need under the state’s standards for financial eligibility in such a plan.

CE
Continuing Education

CHF
Congestive Heart Failure

CHMS
Child Health Management Services

Claim
A claim is a request for payment for a provided service. "Claim" and "Bill" are used for all Part A and Part B services billed through Fiscal Intermediaries. "Claim" is used for Part B physician/supplier services billed through the Carrier.

Clinic
(1) A facility for diagnosis and treatment of outpatients. (2) A group practice in which several physicians work together.

Closed-end Provider Agreement
An agreement for a specific period of time not to exceed 12 months which must be renewed in order for the provider to continue to participate in the Title XIX Program.

CME
Continuing Medical Education

CMHC
Community Mental Health Center

CMS
Children’s Medical Services; also refers to Centers for Medicare & Medicaid Services

Coinsurance
The portion of allowed charges the patient is responsible for under Medicare. This may be covered by other insurance such as Medi-Pak or Medicaid (if entitled). This also refers to the portion of a Medicaid covered inpatient hospital stay for which the recipient is responsible.

Confidentiality
Your right to talk with your health care provider without anyone else finding out what was discussed.

Continuing Care Retirement Community (CCRC)
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 fulltime 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.

Contract
Written agreement between a provider of medical services and the Arkansas Division of Medical Services. A contract must be signed by each provider of services participating in the Medicaid Program.

Copayment
In some Medicare health plans, this is the amount that you pay for each medical service you get, like a doctor visit. In the Medicare program, a copayment is usually a set amount you pay for a service, like $5.00 or $10. 00 for a doctor visit.
Co-pay
The portion of the total charge for medical services that the insured or recipient must pay.

Cosmetic Surgery
Any surgical procedure directed at improving appearance but not medically necessary.

Cost Sharing
The cost for medical care that you pay yourself, like a copayment, coinsurance, or deductible.

Coverage (HINN)
A written discharge notice given to people who have original Medicare.

Covered Service
Service which is within the scope of the Arkansas Medicaid Program.

CPT
Physicians’ Current Procedural Terminology

Credit Claim
A claim transaction which has a negative effect on a previously processed claim.

CAH
Critical Access Hospital
Need Definition

Crossover Claim
A claim for which both Titles XVIII (Medicare) and XIX (Medicaid) are liable for services rendered to a recipient entitled to benefits under both programs.

Custodial Care
Personal care, such as bathing, cooking, and shopping, that is not covered by the Medicare program.

The Centers for Medicare and Medicaid Services (CMS)
The federal agency within the Department of Health and Human Services that runs the Medicare, Medicaid, Clinical Laboratories (under CLIA program), and Children's Health Insurance programs, and works to make sure that the beneficiaries in these programs are able to get high quality health care.

DAAS
Division of Aging and Adult Services

Date of Service
Date or dates on which a recipient receives a covered service. Documentation of services and units received must be in the recipient’s record for each date of service.

DBS
Division of Blind Services

DCFS
Division of Children and Family Services

DCO
Division of County Operations

DDS
Developmental Disabilities Services

Debit Claim
A claim transaction which has a positive effect on a previously processed claim.

Deductible
The amount the Medicare recipient must pay toward covered benefits before Medicare or insurance payment can be made for additional benefits. Medicare Part A and Part B deductibles are paid by Medicaid within the program limits.

DHS
Department of Health & Human Services

Denial
A claim for which payment is disallowed.

Department of Human Services (DHS)
Administers the Medicare program through its divisions, Social Security Administration and The Centers for Medicare and Medicaid Services.

Dependent
A spouse or child of the individual who is entitled to benefits under the Medicaid Program.

Diagnosis
The identity of a condition, cause or disease.

Diagnostic Admission
Admission to a hospital primarily for the purpose of diagnosis.

Diagnosis Related Groups (DRGS)
A way for Medicare to pay hospitals based on diagnosis, age, sex, and complications.

Disallow
To subtract a portion of a billed charge which exceeds the Medicaid maximum allowable fee or to deny an entire charge because Medicaid pays Medicare Part A and B deductibles subject to program limitations for eligible recipients.

Discharge Planning
The process that social workers or other health professionals use to decide what a patient needs to make a smooth transition from one level of care to another, such as 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.

Discounts
A discount is defined as the lowest available price charged by a provider to a client or third party payor, including any discount, for a specific service during a specific period of time by an individual provider. If a Medicaid provider offers a professional or volume discount to any customer, the same discount must exist for claims submitted to Medicaid.
Example: If a laboratory provider charges a private physician or clinic a discounted rate for services, the charge submitted to Medicaid for the same service must not exceed the discounted price charged to the physician or clinic. Medicaid must be given the benefit of discounts and price concessions the lab gives any one of its customers.

Disenroll
Leaving or ending your health care coverage with a health plan.

DME Durable Medical Equipment
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 Medicare Part B.

DMHS
Division of Mental Health Services

DMS
Division of Medical Services (Medicaid)

DO
Doctor of Osteopathy

DOS
Date of Service

Duplicate Claim
A claim which has been submitted or paid previously or a claim which is identical to a claim in process.

Durable Medical Equipment
Equipment which (1) can withstand repeated use and (2) is used to serve a medical purpose. Examples include a wheelchair or hospital bed.

DYS
Division of Youth Services

EAC
Estimated Acquisition Cost

EDS
Electronic Data Systems
Electronic Data Systems Corporation (EDS)
Current fiscal agent for the state Medicaid program.

EFT
Electronic Funds Transfer

Elderly Pharmaceutical Insurance Coverage (EPIC)
Coverage that can help Medicare beneficiaries pay for their prescription medicine, depending on income.

Eligible
(1) To be qualified for Medicaid benefits. (2) One who is qualified for benefits.

Eligibility File
(1) To be qualified for Medicaid benefits. (2) One who is qualified for benefits.

Emergency Care
Care to treat severe pain, an injury, sudden illness, or suddenly worsening illness that you believe may cause serious danger to your health if you do not get immediate medical care. Medicare health plans must provide access to emergency care services 24 hours a day, 7 days a week. Your plan must pay for your emergency care and cannot require prior approval for emergency care you receive from any provider. You can receive emergency care anywhere in the United States. Under the Original Medicare Plan, you can always go to any hospital of your choice, not only in an emergency.

Emergency Services
Inpatient or outpatient hospital services that a prudent layperson with an average knowledge of health and medicine would reasonably believe are necessary to prevent death or serious impairment of health and which, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.
Source: 42 U.S. Code of Federal Regulations §422.2 and §424.101.

Enrollment
Period of time during which people can enroll in an insurance policy, original Medicare or Health Maintenance Organization (HMO).

EOMB
Explanation of Medicare Benefits
A notice that is sent to you after the doctor files a claim for Part B services under the Original Medicare Plan. This notice explains what the provider billed for, the approved amount, how much Medicare paid, and what you must pay. This is being replaced by the Medicare Summary Notice (MSN), which sums up all services over a certain period of time, generally monthly. (See Medicare Summary Notice; Medicare Benefits Notice.)

EPSDT
Early and Periodic Screening, Diagnosis and Treatment

Error Code
A numeric code indicating the type of error found in processing a claim.

Estimated Acquisition Cost
The estimated amount a pharmacy actually pays to obtain a drug.

Experimental Surgery
Any surgical procedure considered experimental in nature.

Explanation of Medicaid Benefits (EOMB)
A statement mailed once per month to selected recipients to allow them to confirm the Medicaid service which they received.

Family Planning Services
Any medically approved diagnosis, treatment, counseling, drugs, supplies or devices which are prescribed or furnished by a physician, nurse practitioner, certified nurse-midwife or the Health Department to individuals of child-bearing age for purposes of enabling such individuals freedom to determine the number and spacing of their children.

Field Audit
An activity performed whereby a provider’s facilities, procedures, records and books are audited for conformance to Medicaid standards. A field audit may be conducted on a routine basis, or on a special basis.

Fiscal Agent
An organization authorized by the State of Arkansas to process Medicaid claims.

Fiscal Agent Intermediary
A private business firm which has entered into a contract with the Arkansas Department of Health & Human Services to process Medicaid claims.

Fiscal Intermediary (FI)
A private insurance company that contracts with the Centers for Medicare & Medicaid Services (CMS), formerly called HCFA, to process beneficiary bills (claims) for Medicare Part A Services.

Fiscal Year
The twelve-month period between settlements of financial accounts.

Formulary
A list of certain drugs and their proper dosages. In some Medicare health plans, doctors must order or use only drugs listed on the plan's formulary.

Fraud and Abuse
Fraud:To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service provided.
Abuse:Sending in claims or bills for services that should not be paid by Medicare or Medicaid. This is not the same as fraud.

Free Look (Medigap)
Period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled.

Gaps (also called Medicare Gaps)
The costs or services that are not paid for under the Original Medicare Plan.

Generic Upper Limit (GUL)
The maximum drug cost which may be used to compute reimbursement for specified multiple-source drugs unless the provisions for a Generic Upper Limit override have been met. The Generic Upper Limit may be established or revised by the Health Care Financing Administration (HCFA) or by the State Agency.

Grievance
Complaints about the way your Medicare health plan is providing your care (other than complaints concerning your request for a service or payment), such as cleanliness of the health care facility, problems calling the plan by phone, staff behavior, or operating hours.

Group or Network HMO
A health plan that contracts with group practices of doctors to provide health care services in one or more places.

Group Practice
A medical practice in which several practitioners render and bill for services under a single provider number.

Guaranteed Renewable Policy
A medical policy that your insurance company must allow you to continue unless you do not pay your premiums.

GUL
Generic Upper Limit

HCBS
Home and Community Based Services

HCFA
Health Care Financing Administration (Former name for CMS Centers for Medicare & Medicaid Services)

HCQIP
Healthcare Quality Improvement Program

Health care provider
A person who is trained and licensed to give health care. Also, a place licensed to give health care. Doctors, nurses, hospitals, skilled nursing facilities, some assisted living facilities, and certain kinds of home health agencies are examples of health care providers. Long-Term Care Ombudsman. An advocate who works to resolve problems between residents and nursing homes, as well as assisted living facilities.

Health Employer Data and Information Set (HEDIS®)
A set of standard performance measures that can give you information about the quality of a health plan. You can get information on the effectiveness of care, access, cost, and other measures you can use to compare the quality of managed care plans. The National Committee for Quality Assurance (NCQA) collects HEDIS data. (See National Committee for Quality Assurance.)

Health Insurance Claim Number
Number assigned to Medicare recipients and individuals eligible for SSI.

Health Maintenance Organization (HMO)
A group of doctors, hospitals, and other health care providers who have agreed to provide care to Medicare beneficiaries in exchange for a fixed amount of money from Medicare every month. In an HMO, you usually must get all your care from the providers that are part of the plan.

Health Maintenance Organization (HMO) with a Point of Service Option (POS)
A type of managed care plan that allows you to use doctors and hospitals outside the plan for an additional cost.

Health Insurance Information Counseling and Assistance Program (HIICAP)
HIICAP offers free current unbiased information on Medicare, Medigap policies, Medicare HMOs, Medicaid eligibility, and long term care insurance. HIICAP counselors help beneficiaries with their questions and paperwork.

HHS
The Federal Department of Health and Human Services

HIC Number
Health Insurance Claim Number

Hospital
An institution which meets the following qualifications:

1. Provides diagnostic and rehabilitation services to inpatients.
2. Maintains clinical records on all patients.
3. Has by-laws with respect to its staff of physicians.
4. Requires each patient to be under the care of a physician, dentist or certified nurse-midwife.
5. Provides 24-hour nursing service.
6. Has a hospital utilization review plan in effect.
7. Is licensed by the State.
Meets other health and safety requirements set by the Secretary of Health and Human Services.

Hospital-Based Physician
A physician who is a hospital employee and is paid for services by the hospital.

Hospital Issued Notice of Noncoverage (HINN)
Document issued by a hospital stating that Medicare will no longer pay for the hospital stay, due to the patient no longer needing acute or skilled services.

Home Health Agency
An organization that provides home care services, including skilled nursing care, physical therapy, occupational therapy, speech therapy, and care by home health aides.

Home Health Care
Health care that is given at home, such as physical therapy or skilled nursing care. It is different from at-home recovery care, which is help with bathing, eating, and other daily living activities. (See Activities of Daily Living.)

Hospice
A special way of caring for people with a terminal illness that provides medical, emotional, and social help in a comfortable and familiar place, usually the patient's own home. Hospice care is covered by Medicare whether you are in the Original Medicare Plan or another Medicare health plan.
Hospital Insurance (Part A)
The part of Medicare that covers hospice care, home health care, skilled nursing facilities, and inpatient hospital stays.

HPMP
Hospital Payment Monitoring Program

IADL
Instrumental Activities of Daily Living

ICD-9-CM
International Classification of Diseases, Ninth Edition, Clinical Modification

ICF/MR
Intermediate Care Facility/ Mental Retardation

ICN
Internal Control Number

ID Card
An identification card issued to Medicaid recipients containing the encoded data to permit a provider to access the recipient’s Medicaid eligibility information.

Inpatient
A patient admitted to a hospital or skilled nursing facility who occupies a bed and receives inpatient services.

In-Process Claim (Pending Claim)
A claim which suspends during system processing for suspected error conditions because all processing requirements are not met. These conditions must be reviewed by EDS or DMS and resolved before processing of the claim can be completed. (See suspended claim.)

Inquiry
A request for information.

Institutional Care
Care in an authorized private, non-profit, public or state institution or facility. Such facilities include schools for the deaf, and/or blind and institutions for the handicapped.

Instrumental Activities of Daily Living (IADL)
Tasks which are ordinarily performed on a daily or weekly basis and include meal preparation, housework, laundry, shopping, taking medications and travel/transportation.

Intensive Care
Isolated and constant observation care to patients critically ill or injured.

Interim Billing
A claim for less than the full length of an inpatient hospital stay. Also, a claim which is billed for services provided to a particular date even though more services will be provided. It may or may not be the final bill for a particular recipient’s services.

Internal Control Number (ICN)
The unique 13 digit claim number which appears on a Remittance Advice.

International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9CM)
A diagnosis coding system for identifying a patient’s diagnosis on a claim used by medical providers.

Investigational Product
Any product which is considered investigational, experimental and not approved by the Food and Drug Administration. The Arkansas Medicaid Program does not cover investigational products.

JCAHO
Joint Commission on the Accreditation of Healthcare Organizations

Julian Date
Chronological date of the year, 001 through 365 or 366, preceded by a two (2) digit year designation. Claim number example: 97231.

Length Of Stay
Period of time a patient is in the hospital. Also, the number of days covered by Medicaid within a single inpatient stay.

Lifetime Reserve Days
Sixty days that Medicare will pay for when you are in a hospital for more than 90 days. These 60 reserve days can be used only once in a lifetime. For the lifetime reserve days (91–150) Medicare pays for all covered costs except for coinsurance of $406 a day (2002 amount).

Line Item
A service provided to a recipient. A claim may be made up of one or more line items for the same recipient. Also called a claim detail.

LTC
Long-Term Care
Custodial care provided at home or in a nursing home for people with chronic disabilities and prolonged illnesses. Long term care is not covered by Medicare.

Office of Long Term Care (OLTC)
An office within the Arkansas Division of Medical Services responsible for nursing facilities.

Long-Term Care Ombudsman
A supporter for nursing home patients who works to solve problems between patients and nursing homes. This supporter is referred to as an "Ombudsman."

Managed Care Plan
A group of doctors, hospitals, and other health care providers who have agreed to give health care to Medicare beneficiaries in exchange for a fixed amount of money from Medicare every month. Managed care plans include Health Maintenance Organizations (HMO), HMOs with a Point of Service Option (POS), Provider Sponsored Organizations (PSO), and Preferred Provider Organizations (PPO).

MAC
Maximum Allowable Cost
The maximum drug cost which may be reimbursed for specified multi-source drugs. This term was replaced by generic upper limit.

MD
Medical Doctor

Mediation
An approach to resolving or settling complaints or differences between two parties. It can be used effectively in health care situations.

Medicaid
A joint Federal and State program that helps with medical costs for people with low incomes and limited resources. Medicaid programs vary from State to State, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medicaid Management Information System (MMIS)
The automated system utilized to process Medicaid claims.

Medical Assistance Section
A section within the Arkansas Division of Medical Services responsible for administering the Arkansas Medical Assistance Program.

Medically Needy
Individuals whose income and resources exceed those levels for assistance established under a state or federal plan, but are insufficient to meet costs of health and medical services.

Medical Necessity
All Medicaid benefits are based upon medical necessity. A service is “medically necessary” if it is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions which endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap or cause physical deformity or malfunction and if there is no other equally effective (although more conservative or less costly) course of treatment available or suitable for the recipient requesting the service. For this purpose, a “course of treatment” may include mere observation or (where appropriate) no treatment at all. The determination of medical necessity may be made by the Medical Director for the Medicaid Program, Professional Review Organization or Peer Review Committee for the Medicaid Program. Coverage may be denied if the requested service is not medically necessary according to the preceding criteria or is generally regarded by the medical profession as experimental or unacceptable, unless objective clinical evidence demonstrates circumstances making the requested services necessary.

Medical Insurance (Part B)
The part of Medicare that covers doctors' services, outpatient hospital care, and other medical services that Part A doesn't cover, such as physical and occupational therapy.

Medicare
The federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD)(those with permanent kidney failure who need dialysis or a transplant).

Medicare Benefits Notice
A notice you get after your doctor files a claim for Part A services under the Original Medicare Plan. This notice explains what the provider billed for, the approved amount, how much Medicare paid, and what you must pay. You might also get an Explanation of Medicare Benefits (EOMB) (for Part B services) or a Medicare Summary Notice (MSN). (See Explanation of Medicare Benefits; Medicare Summary Notice.)

Medicare+Choice
A new Medicare program that allows for more choices among Medicare health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease.
Medicare Coverage
Medicare coverage is made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B).

Medicare Medical Savings Account Plan (MSA)
A Medicare health plan option made up of two parts. One part is a Medicare MSA Health Insurance Policy with a high deductible. The other part is a special savings account where Medicare deposits money to help you pay your medical bills.

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

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

Medicare Summary Notice (MSN)
A notice you receive after the doctor files a claim for Part A and Part B services under the Original Medicare Plan. This notice explains what the provider billed for, the approved amount, how much Medicare paid, and what you must pay. You might also get a notice called an Explanation of Medicare Benefits (EOMB) for Part B services. (See Explanation of Medicare Benefits; Medicare Benefits Notice.)

Medicare Saving Programs
Medicare programs that help you pay some Medicare out-of-pocket expenses.

Medigap
Medicare supplemental insurance policies that are sold by private insurance companies to Medicare beneficiaries to fill the "gaps" in Original Medicare Plan coverage. There are ten standardized policies, labeled Plan A through Plan J. Your State decides which of the 10 policies can be sold in your State. Medigap policies only work with the Original Medicare Plan. (See Gaps; Supplemental Insurance.)

Mis-Utilization
Any usage of the Medicaid Program by any of its providers and/or recipients which is not in conformance with both State and Federal regulations and laws (includes fraud, abuse and defects in level and quality of care).

MMCS
Medicaid Managed Care Services
A Division of Arkansas Foundation for Medical Care

MMIS
Medicaid Management Information System

MNIL
Medically Needy Income Limit

NDC
National Drug Code
The unique eleven digit number assigned to drugs which identifies the manufacturer, drug, strength and package size of each drug.

NET
Non-emergency Transportation Program
The Arkansas Medicaid NET program provides eligible Medicaid recipients with transportation to the nearest qualified Medicaid provider.This program is provided through the Division of Medical Services (DMS), which contracts with nine transportation brokers throughout the state.

NF
Nursing Facility

NHQI
Nursing Home Quality Iniative

Non-Covered Services
Services not medically necessary, services provided for the personal convenience of the patient or services not covered under the Medicaid Program.

Nonpatient
An individual who receives services, such as laboratory tests, performed by a hospital, but who is not a patient of the hospital.

Notice of Discharge and Medicare Appeal Rights (NODMAR)
A written discharge notice that states if a beneficiary chooses to stay in the hospital, he/she will be responsible for services provided beginning on the third day after the notice has been received; the notice also explains the Medicare appeal process.

Notice of Medicare Benefits
Statements that Medicare sends you to show what action was taken on a claim (See Explanation of Medicare Benefits; Medicare Benefits Notice; Medicare Summary Notice.)

Nurse Practitioner
A professional nurse with credentials which meet the requirements for licensure as a nurse practitioner in the State of Arkansas.

Nursing home
A residence that provides a room, meals, and help with activities of daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance.

OBQI
Outcome Based Quality Improvement

Original Medicare Plan
The traditional pay-per-visit health plan that lets you go to any doctor, hospital, or other health care provider who accepts Medicare. You pay the deductible. Medicare pays its share of the Medicare-approved mount, and you pay your share (coinsurance). The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Out-Of-Pocket Costs
Health care costs that you must pay because they are not covered by insurance.

Outpatient
A patient receiving medical services, but not admitted as an inpatient to a hospital.

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

Over-Utilization
Any over usage of the Medicaid Program by any of its providers and/or recipients not in conformance with professional judgement and both State and Federal regulations and laws (includes fraud and abuse).

PA
Prior Authorization
PA can also be referred to as Physician Advisor

Participant
A provider of services who: (1) provides the service, (2) submits the claim and (3) accepts the amount determined to be the reasonable charge for the services provided as payment in full.

Patient
A person under the treatment or care, of a physician or surgeon, or in a hospital.

Payment
Reimbursement to the provider of services for rendering a Medicaid covered benefit.

Pay to Provider
A person, organization or institution authorized to receive payment for services provided to eligible Medicaid recipients by a person or persons who are a part of the entity.
Pay to Provider Number
A 9-digit number assigned to each Pay to Provider. Medicaid reports provider payments to the Internal Revenue Service under the Employee Identification Number “Tax ID” linked in the Medicaid Provider File to the pay to provider number.

PCP
Primary Care Physician

Peer
A person or committee in the same profession as the provider.

Peer Review
An activity performed by a group or groups of practitioners or other providers, by which the practices of their peers are reviewed for conformance to generally accepted standards.

Per Diem
A daily rate paid to institutional providers.

Performing Physician
The physician providing, supervising, or both, a medical service and claiming primary responsibility for ensuring that services are delivered as billed.

Person
Any natural person, company, firm, association, corporation or other legal entity.

Physician’s Current Procedural Terminology
An AMA approved listing of medical terms and identifying codes for reporting medical services and procedures performed by physicians.

POC
Plan of Care
A document utilized by a provider to plan, direct or deliver care to a patient to meet specific measurable goals. Also called care plan, service plan or treatment plan.

POS
Place of Service or Point of Sale, depending on usage
An alpha or numeric code denoting the actual place services are provided.

Postpayment Utilization Review
The review of services and practice after payment.

Practitioner
An individual provider; one who practices in a health or medical service profession.

Premium
Your monthly payment for health care coverage to Medicare, an insurance company, or a health care plan.

Prepayment Utilization Review
The review of services and practice patterns before payment.

Prescription
A health care professional’s legal order for a drug which, in accordance with federal and/or state statutes, may not be obtained otherwise. Also means an order for a particular Medicaid covered service.

Prescription Drug (RX)
A drug which, in accordance with federal and/or state statutes, may not be obtained without a valid prescription.

Preventive Care
Care to keep you healthy or to prevent illness, such as routine checkups and some tests like colorectal cancer screening, yearly mammograms, and flu shots.

Primary Care
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.

Primary Care Physician (PCP)
A physician responsible for the management of a recipient’s total medical care. Selected by the recipient to provide primary care services and health education. The PCP will monitor on an ongoing basis the recipient’s condition, health care needs and service delivery and also be responsible for locating, coordinating and monitoring medical and rehabilitation services on behalf of the recipient and refer the recipient for most specialty services, hospital care and other services.

Prior Authorization (PA)
The approval by the Arkansas Division of Medical Services or a designee of the Division of Medical Services, for specified services for a specified recipient to a specified provider before the requested services may be performed and before payment will be made.

Private Contract
A contract between you and a doctor or other provider who has decided not to offer services through the Medicare program. This doctor can not 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.

Private Fee-For-Service Plan
A private insurance plan that accepts Medicare beneficiaries. You may go to any doctor or hospital you want. The insurance plan, rather than the Medicare program, decides how much you pay for the services you receive. You may pay more for Medicare covered benefits. You may have extra benefits the Original Medicare Plan doesn't cover.

Participating Facility, Provider, or Supplier
A health care facility, doctor, or therapist, or equipment supplier that participates in Medicare and accepts payment for services received by Medicare beneficiaries.

Primary Payer
The insurance company that pays first on a claim for someone on Medicare. This would be Medicare or some other insurance, i.e., an employee group health plan.

Procedure Code
A five digit numeric or alpha numeric code to identify medical services and procedures on medical claims.

Professional Component
A physician’s interpretation or supervision and interpretation of laboratory, X-ray or machine test procedures.

Professional Review Organization (PRO)
Now referred to as the (QIO) Quality Improvement Organization
The Professional Review Organization is the federally mandated review organization for the state under the authority of the Arkansas Foundation for Medical Care, Inc. This organization monitors hospital and physician services billed to the state’s Medicare intermediary and the Medicaid program to assure high quality, medical necessity and appropriate care for each patient’s needs.

Profile
A detailed view of an individual provider’s charges to Medicaid for health care services or a detailed view of a recipient’s usage of health care services.

Provider
A person, organization or institution enrolled to provide health or medical care services authorized under the State Title XIX Medicaid Program.

Provider Relations
The activity within the Medicaid Program which handles all relationships with Medicaid providers.

Provider Number
A nine-character code assigned to each provider of services in the Arkansas Medicaid Program for identification purposes.

Quality Assurance
The process of looking at how well a medical service is provided. The process may include formally reviewing health care given to a person, or group of persons, locating the problem, correcting the problem, and valuating actions taken.

Quality Improvement Organization (QIO)
Groups of practicing doctors and other health care experts paid by the Federal Government to monitor and improve the care given to Medicare patients. They must review your complaints about the quality of care provided by inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare managed care plans, and ambulatory surgical centers.

Qualified Medicare Beneficiaries (QMB)
Persons who have Medicare Part A, low monthly incomes and limited resources, but who are not otherwise eligible for Medicaid. If you qualify for QMB, Medicaid pays for Part A premium and deductibles and co-insurance amounts for services provided by Medicare providers. Check with your state, county or local Medicare Assistance office to see if you qualify for this program or other programs.

QIO
Quality Improvement Organization

QIRA
Quality Improvement Rapid Assesment

RA
Remittance Advice. Also called Remittance and Status Report.

Railroad Claim Number
The number issued by the Railroad Retirement Board to control payments of annuities and pensions under the Railroad Retirement Act. The claim number begins with a one to three letter alphabetic prefix denoting the type of payment, followed by six or nine numeric digits.

Recipient
Person who meets the Medicaid eligibility requirements, receives an ID card and is eligible for Medicaid services.

Referral
An authorization from a Medicaid enrolled provider to a second Medicaid enrolled provider. The receiving provider is expected to exercise independent professional judgment and discretion, to the extent permitted by laws and rules governing the practice of the receiving practitioner, and develop and deliver medically necessary services covered by the Medicaid program. The provider making the referral may be a physician or another qualified practitioner acting within the scope of practice permitted by laws or rules. Medicaid requires documentation of the referral in the recipient’s medical record, regardless of the means the referring provider makes the referral. Medicaid requires the receiving provider to document the referral also, and to correspond with the referring provider regarding the case when appropriate and when the referring provider so requests.

Reimbursement
The amount of money remitted to a provider.

RFP
Request for Proposal

Rejected Claim
A claim for which payment is refused.

Relative Value
A weighting scale used to relate the worth of one surgical procedure to any other. This evaluation, expressed in units, is based upon the skill, time and the experience of the physician in its performance.

Remittance
A remittance advice.

Reported Charge
The total amount submitted in a claim detail by a provider of services for reimbursement.

Retroactive Medicaid Eligibility
Medicaid eligibility which may begin up to three (3) months prior to the date of application provided all eligibility factors are met in those months.

Returned Claim
A claim which is returned by the Medicaid Program to the provider for correction or change to allow it to be processed properly.

RA
Remittance Advice
A notice sent to providers advising the status of claims received, including paid, denied, in-process and adjusted claims. It includes year-to-date payment summaries and other financial information.

RTP
Return to provider or to return a claim to the provider

Sanction
Any corrective action taken against a provider.

Screening
The use of quick, simple medical procedures carried out among large groups of people to sort out apparently well persons from those who may have a disease or abnormality and to identify those in need of more definitive examination or treatment.

Signature
Signature or initials means the person’s original signature, or the person’s signature or initials may be recorded by an electronic or digital method executed or adopted by the person with the intent to be bound by or to authenticate a record. An electronic signature must comply with Arkansas Code Annotated § 25-31-101-105, including verification through an electronic signature verification company and data links invalidating the electronic signature if the data is changed.

Single State Agency
The state agency authorized to administer or supervise the administration of the medical assistance program on a statewide basis.

Skilled Nursing Care
A level of care that must be given or supervised by licensed nurses and is under the general direction of a doctor. Examples of Skilled Nursing Care include: getting intravenous injections, tube feeding, oxygen to help you breathe, and changing sterile dressings on a wound. Any service that could be safely performed by an average nonmedical person or one's self, without the direct supervision of a licensed nurse, is not covered.

SNF
Skilled Nursing Facility
A nursing home, or a distinct part of a facility, licensed by the Office of Long Term Care as meeting the Skilled Nursing Facility Federal/State licensure and certification regulations. A health facility which provides skilled nursing care and supportive care on a 24-hour basis to residents whose primary need is for availability of skilled nursing care on an extended basis.

SSA
Social Security Administration
Determines eligibility for Medicare, handles enrollment and conducts Part A and Part B Hearings.
A federal agency which makes disability and blindness determinations for the Secretary of the HHS.

Social Security Claim Number
The account number used by SSA to identify the individual on whose earnings SSA benefits are being paid. It is the Social Security Account Number followed by a suffix, sometimes as many as three characters, designating the type of beneficiary (e.g., wife, widow, child, etc.).

Source of Care
A hospital, clinic, physician or other facility which provides services to a beneficiary under the Medicaid Program.

SSI
Supplemental Security Income
A program administered by the Social Security Administration. This program replaced previous state administered programs for aged, blind or disabled recipients (except in Guam, Puerto Rico and the Virgin Islands). This term may also refer to the Bureau of Supplemental Security Income within SSA which administers the program.

Specialty
The specialized area of practice of a physician or dentist.

Spend Down (SD)
The amount of money a recipient must pay toward medical expenses when income exceeds the Medicaid financial guidelines. A component of the medically needy program allows an individual or family whose income is over the medically needy income limit (MNIL) to use medical bills to spend excess income down to the MNIL. The individual(s) will have a spend down liability. The spend down column of the remittance advice indicates the amount which the provider may bill the recipient. The spend down liability occurs only on the first day of Medicaid eligibility.

Status Report
A remittance advice.

Supplemental Insurance
There are many types of private health insurance/coverage that you can buy to supplement, or fill the gaps, in your Medicare coverage. This supplemental insurance will pay for some or all of your health care costs that are not covered by Medicare. These types of private health insurance/ coverage include:

• Employee Coverage (from your employer or union);
• Retiree Coverage (from your employer or union); and
• Medigap Insurance (from a private company or group).
  People often refer to all of these types of private health insurance/coverage as supplemental insurance. However, "Medicare Supplemental" or "Medigap" insurance is a specific type of private insurance that is subject to Federal and State laws. (See Gaps; Medigap.)

Supplier
A health care facility, doctor, or therapist, or equipment supplier that participates in Medicare and accepts payment for services received by Medicare beneficiaries.

Suspended Claim
An “In-Process Claim” which must be reviewed and resolved.

Suspension from Participation
An exclusion from participation for a specified period of time.

Suspension of Payments
The withholding of all payments due to a provider until the resolution of a matter in dispute between the provider and the state agency.

Termination from Participation
A permanent exclusion from participation in the Title XIX Program.

TPL
Third Party Liability
A condition whereby a person or an organization, other than the recipient or the state agency, is responsible for all or some portion of the costs for health or medical services incurred by the Medicaid recipient (e.g., a health insurance company, a casualty insurance company or another person in the case of an accident, etc.).

UR
Utilization Review
The section of the Arkansas Division of Medical Services which performs the monitoring and controlling of the quantity and quality of health care services delivered under the Medicaid Program.

Urgently Needed Care
An unexpected illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than the Original Medicare Plan. If you are out of your plan's service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care.

VRS
Voice Response System
Voice activated system to request prior authorization for prescription drugs and for PCP assignment and change.

Void
A transaction which deletes.

Ward
An accommodation of five or more beds.

Withholding of Payments
A reduction or adjustment of the amounts paid to a provider on pending and subsequently due payments.

Worker’s Compensation
A type of Third-Party Liability for medical services rendered as the result of an on-the-job accident or injury to a recipient for which the employer’s insurance company may be obligated under ’s Compensation Act.