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| ACRONYMS | Go To Acronym Search on CMS.gov |
| ALJ | Administrative Law Judge |
| ASC | Ambulatory Surgical Center |
| AUSA | Assistant United States Attorney |
| BENE | Beneficiary |
| CHAMPUS | Civilian Health and Medical Plan of the Uniformed Services |
| CHOW | Change of Ownership |
| CMHC | Community Mental Health Center |
| CMN | Certificate of Medical Necessity |
| CMS | Centers for Medicare & Medicaid Services (formerly known as HCFA) |
| CORF | Comprehensive Outpatient Rehabilitation Facility |
| CPT | "Physicians' Current Procedural Terminology" |
| CWF | Common Working File |
| DDE | Direct Data Entry |
| DME | Durable Medical Equipment |
| DMERC | Durable Medical Equipment Regional Carrier |
| DOJ | Department of Justice |
| DRG | Diagnosis Related Group |
| EMC | Electronic Media Claims |
| ERA | Electronic Remittance Advice |
| ESRD | End Stage Renal Disease |
| FI | Fiscal Intermediary |
| FISS | Fiscal Intermediary Standard System |
| GAO | General Accounting Office |
| GME | Graduate Medical Expense |
| HCFA | Health Care Financing Administration (see CMS) |
| HHA | Home Health Agency |
| HHS | Health and Human Services |
| HIPAA | Health Insurance Portability and Accountability Act |
| HOSP | Hospital |
| IME | Indirect Medical Education |
| LTC | Long Term Care |
| MFIS | Medicare Fraud Information Specialist |
| MSN | Medicare Summary Notice |
| MSP | Medicare Secondary Payer |
| OIG | Office of Inspector General |
| ORF | Outpatient Rehabilitation Facility |
| ORT | Operation Restore Trust |
| OT | Occupational Therapy |
| PHP | Partial Hospitalization Program |
| PPS | Prospective Payment System |
| PT | Physical Therapy |
| RHC | Rural Health Clinic |
| RHHI | Regional Home Health Intermediary |
| RMFA | Restricted Medicare Fraud Alert |
| SNF | Skilled Nursing Facility |
| SSI | Social Security Income |
| SSN | Social Security Number |
| ST | Speech Therapy |
| UMFA | Unrestricted Medicare Fraud Alert |
| UR | Utilization Review |
| VRU | Voice Response Unit |
| DEFINITIONS | Go To Glossary Search on CMS.gov |
| Acute Hospital | A hospital which provides care for persons who have a crisis, intense or severe illness or condition which requires urgent restorative care. |
| Beneficiary | The person eligible to receive Medicare benefits (sometimes called "bene") |
| Benefit Period Under Medicare | A Medicare benefit period begins upon entry to a qualified hospital and ends when the patient has been out of a hospital and not receiving Medicare benefits in a facility primarily providing skilled nursing or rehabilitation services for 60 consecutive days, including the day of discharge. |
| Carrier | A commercial health insurance company under contract with the Centers for Medicare & Medicaid Services (CMS) to handle claims processing for Medicare Part B, including the payment of claims for items and services provided in a given area. |
| Certificate of Medical Necessity | A document completed and signed by a physician to certify a patient's need for certain types of durable medical equipment (e.g. wheelchairs, walkers, etc.). |
| Charges | Prices assigned to units of medical service, such as a visit to a physician or a day in the hospital. Charges for services may not be related to the actual costs of providing the services. Further, the methods by which charges are related to costs vary substantially from service to service and from institution to institution. |
| Claims | A bill requesting that medical services be paid by Medicare or by some other insurance company. |
| Coordination of Benefits | Provisions and procedures used by insurers to avoid duplicate payments for losses insured under more than one policy. One of the insurers is usually the primary payer assuring that no more than 100% of the costs are covered. This does not usually apply to indemnity (cash payment) policies. Also see "Medicare as Secondary Payer". |
| Co-payment | A specified dollar amount or percentage of covered expenses which the beneficiary is required to pay towards medical bills. Medicare Part A Hospital Insurance requires that a co-payment or co-insurance, is paid by the beneficiary for certain covered services, and the 21st through the 100th day of skilled nursing facility care. Medicare Part B pays 80% of "approved" charges and the beneficiary must pay the 20% coinsurance and the balance of the charges. |
| Costs | Expenses incurred in the provision of services or goods. Charges billed to an individual or third party may not necessarily be the same, as based on the costs. Hospitals often charge more for a given service than it actually costs in order to recoup losses incurred from providing other services where costs exceed feasible charges. |
| Covered Services | Medicare law permits payment only for services that are "reasonable and necessary for the diagnosis or treatment of an illness or injury". Therefore, Medicare can pay for services only as long as they are medically necessary. |
| CPT | "Physicians' Current Procedural Terminology", yearly publication of the American Medical Association. A listing of the descriptive terms and the numeric identifying codes and modifiers for describing and reporting medical services and procedures performed by physicians. These codes are required on claims submitted for Medicare payment. |
| Custodial Care | Care is considered custodial when it is primarily for the purpose of meeting personal needs and could be provided by persons without professional skills or training. For example, custodial care includes help in walking, getting in and out of bed, bathing, dressing, eating, toileting, and taking medicine. (These may also be referred to as Activities of Daily Living or ADLS.) |
| Deductible | An initial amount of medical expense for which the beneficiary is responsible before Medicare or an insurance policy will pay. |
| Demand Bill | When a provider determines that the care to be provided is not covered, the beneficiary must be notified in writing. If a beneficiary is unwilling to accept the provider's decision of noncoverage, the beneficiary may request a bill to be submitted to the intermediary on their behalf. All "demand bills" are reviewed 100% by Medicare for a coverage decision. |
| Diagnostic Related Groups DRG | DRGs are used to determine the amount that Medicare reimburses hospitals for in-patient services. It is part of the Prospective Payment System. Categories of illnesses are divided into more than 470 groups, one of which is assigned to a Medicare patient being discharged from a hospital. The hospital is reimbursed a fixed amount based on the DRG code for the patient. |
| Durable Medical Equipment (DME) | Durable medical equipment, as defined by Medicare, is equipment which can 1) withstand repeated use, 2) is primarily and customarily used to serve a medical purpose, 3) generally not useful to a person in the absence of an illness or injury, and 4) is appropriate for use in the home. Equipment used in the treatment of health conditions and impairments, such as oxygen, wheelchairs, hospital beds, walkers. |
| Durable Medical Equipment Regional Carrier (DMERC) | A commercial health insurance company under contract with the Centers for Medicare & Medicaid Services (CMS) to handle claims processing for durable medical equipment. There are a total of four DMERCs, each servicing a specific geographic area. |
| End Stage Renal Disease (ESRD) | Medical condition in which a person's kidneys no longer function, requiring the individual to receive dialysis or a kidney transplant to sustain his or her life. |
| Enrollment | Procedure in which eligible persons can secure participation in the Medicare program and receive Medicare coverage. It is handled by the Social Security Administration through local Social Security offices. |
| Enrollment Period | Period during which individuals may enroll for an insurance policy, Medicare, or managed care plan. |
| Fee for Service | Method of charging whereby a physician or other practitioner bills for each encounter or service rendered. This is the usual method of billing by the majority of physicians. |
| Fee Schedule | A listing of accepted charges or established allowances for specified medical, dental or other procedures or services. It usually represents either a physician's or third party's standard or maximum charges for the listed procedures. |
| Health Care Financing Administration (CMS) | A branch of the U.S. Department of Health and Human Services. This is the federal agency that is responsible for administering the Medicare and Medicaid programs. |
| Health Insurance Claim (HIC) Number | The unique alpha numeric Medicare entitlement number assigned to a Medicare beneficiary which appears on the Medicare card. (Also referred to as "Medicare number). |
| HHS | A department of the executive branch of the federal government that administers old age, survivors and health care programs. |
| HHA | A public agency or private organization or a subdivision thereof that is primarily engaged in providing skilled nursing services and other therapeutic services; such as physical, speech or occupation therapy, medical or social services and home health aid services, in the patient's place of residence. |
| Health Maintenance Organization (HMO) | An organization that, for a prepaid fee, provides a comprehensive range of health maintenance and treatment services (including hospitalization, preventive care, diagnosis, and nursing). HMOs are sponsored by large employers, labor unions, medical schools, hospitals, medical clinics, and even insurance companies. Development of HMOs was spurred by the federal government in the 1970's as a means to correct the structural, inflationary problems with conventional health care payment systems. |
| Home Health Agency (HHA) | A home health agency is a public or private agency that specializes in giving skilled nursing services, home health aides, and other therapeutic services, such as physical therapy, in the home. |
| Home Health Care | Health care services provided in the home on a part time basis for the treatment of an illness or injury. Medicare pays for home care only if the if care needed is skilled and required on an intermittent basis and is intended to help people recover or improve from an illness, not to provide unskilled services over a long period of time. |
| Hospice | A hospice is a public agency or private organization that primarily provides pain relief, symptom management, and supportive services to terminally ill people and their families in the home. |
| Indemnity | A specific amount paid for a specified occurrence. |
| Initial Enrollment Period | An individual's first opportunity to enroll in Medicare; the seven months surrounding a person's 65th birth month or 24th month of entitlement to disability benefits. |
| Inpatient | A patient who has been admitted at least overnight to a hospital or other health facility for the purpose of receiving a diagnosis, treatment, or other health services. A patient who occupies a regular hospital bed while receiving hospital care, including room, board, special diet and general nursing services. |
| Intermediary | An organization that has entered into an agreement with the Administrator of the Health Care Financing Administration (e.g. TriSpan Health Services) to perform designated functions in the administration of the Medicare program. Intermediary functions include: coverage determinations, fiscal management, provider audits, utilization pattern analysis, resolution of cost disputes, review and reconsideration of determinations, and furnishing of necessary information and reports to CMS. |
| Intermediate Care Facility (ICF) | An ICF provides health related care and services to individuals who do not require the degree of care or treatment given in a hospital or skilled nursing facility, but who (because of their mental or physical condition) require care and services which is greater than custodial care and can only be provided in an institutional setting. |
| Length of Stay | The time a patient stays in a hospital or other health facility. |
| Lifetime Reserve | Medicare Part A provides a 60 day, one time only benefit period beyond the 90th day of hospital coverage. This is not renewable and a co-payment is required. |
| Long Term Care (LTC) | The broad spectrum of medical and support services provided to persons who have lost some or all capacity to function on their own due to chronic illness or condition and who are expected to need such services over a prolonged period of time. Long term care can consist of care in the home, by family members assisted with voluntary or employed help (such as provided by home health care agencies), adult day health care, or care in institutions. |
| Long Term Care Insurance | A policy designed to help alleviate some of the costs associated with long term care needed. Often, benefits are paid in the form of fixed dollar amount (per day or per visit) for covered LTC expenses and may exclude or limit certain conditions from coverage. |
| Mammogram | The X-ray of the breast to diagnose or screen for breast cancer. |
| Managed Care | Medical care delivery system, such as HMO or PPO, where someone "manages" health care services a beneficiary receives; each plan has its own group of hospitals, doctors and other health care providers called a "network"; usually promote preventive health care; may have to pay a fixed monthly premium and a co-payment each time a service is used. |
| Medicaid | Title XIX of the Social Security Act, federally assisted state administered program to finance health care services for low-income persons of all ages. It is supported by Federal and State taxes. |
| Medically Necessary | Medical necessity must be established (via diagnostic and/or other information presented on the claim under consideration) before the carrier or insurer will make payment. |
| Medicare | Title XVIII of the Social Security Act, federal health insurance program for people 65 and older and some under 65 who are disabled. Medicare has two parts. Part A is Hospital Insurance and primarily provides coverage for inpatient care. Part B is Medical Insurance and provides limited coverage for outpatient care, physician services, diagnostic tests, supplies and ambulance services for the diagnosis and treatment of illness or injury. |
| Medicare Appeal (Reconsideration) | Procedure by which a beneficiary who disagrees with the amount Medicare Part B reimbursement can challenge the Medicare carrier or intermediary within six months of the date of the MSN. If dissatisfied with the decision for an amount over $100 beneficiary may request a hearing within 6 months from review letter. If the amount in question is over $500, beneficiary may request a hearing by an Administrative Law Judge within 60 days from the date of the hearing letter. Medicare Part A appeals have different time limits and amounts in controversy limits. |
| Medicare Part A | The same as Medicare Hospital Insurance |
| Medicare Part B | The same as Medicare Medical Insurance |
| Medicare Summary Notice (MSN) | A newly designed format replacing the Explanation of Medicare Benefits form. The MSN shows what action was taken by the carrier or fiscal intermediary in processing the Medicare claim. |
| Medicare as Secondary Payer (MSP) | Situations, defined by law, in which payment may be made only after another source of medical benefits has either paid or denied payment of medical items and/or services. |
| Medicare Supplemental Policy (also known as Medigap) | Type of insurance policy with coverage specifically designed to pay the major benefit gaps in Medicare (deductibles and co-payment). |
| Medigap Policy | Insurance designed to supplement Medicare by "filling some of the gaps left by Medicare coverage." |
| Nonparticipating Facility | Health care facility which does not participate in the Medicare program and generally does not accept Medicare payment for services received in the facility. |
| Nursing Home | Also convalescent hospital. A place where persons reside who need some level of medical assistance and/or assistance with activities of daily living. A term used to cover a wide range of institutions including Skilled Nursing Facilities, Intermediate Care Facilities and Custodial Care Facilities. Not all nursing homes are Medicare approved/certified facilities. |
| Occupational Therapy | Activities designed to improve the useful functioning of physically and/or mentally disabled persons. |
| Office of Inspector General (OIG)/DHHS | The agency within the U.S. Department of Health and Human Services responsible for the investigation of suspected fraud and abuse and performing audits and inspections of HHS programs. The OIG has authority to levy certain sanctions and civil money penalties. |
| Operation Restore Trust (ORT) | The special HHS initiative establishing a two-year demonstration project (May 95- May 97) against fraud, waste and abuse in the Medicare and Medicaid programs. The project targeted areas of high spending growth (home health agencies, nursing homes and durable medical equipment) in the top five states in terms of beneficiary population and expenditures (California, Florida, Illinois, New York and Texas). |
| Outpatient | A patient who receives care at a hospital or other health facility without being admitted to the facility. Outpatient care also refers to care given in organized programs, such as outpatient clinics. |
| Partial Hospitalization Program (PHP) | A program designed to keep patients with severe mental conditions from becoming hospitalized by providing intensive psychotherapy in a day outpatient setting. |
| Participating Facility | Health care facility which participates in the Medicare program and accepts Medicare payment for services received in the facility. |
| Peer Review Organizations (PROs) | Organizations that have a contract with the federal government to oversee quality of care for Medicare beneficiaries in hospitals, skilled nursing facilities, home health agencies, ambulatory surgical centers, and managed care plans. If the quality of care you received from one of these facilities was unsatisfactory or you think you are being discharged from the hospital too early, you may file a written complaint with your state's PRO. |
| Personal Convenience Items | Medicare does not pay for personal convenience items such as a telephone, toothpaste, slippers, television in your room, for private duty nurses, or for any extra charges for a private room unless it is medically necessary. |
| Physical Therapy | Services provided by specially trained and licensed physical therapists in order to relieve pain, restore maximum function, and prevent disability, injury or loss of a body part. |
| Prior Authorization | Approval may be required before a medical services is provided. For procedures which require prior authorization, an insurer can deny coverage for services already provided or for proposed services which are deemed to not be medically necessary. It is generally the responsibility of the provider to obtain the authorization. |
| Primary Payer | Provider of medical coverage first responsible for making payment on a Medicare claim. |
| Prospective Payment System (PPS) | A standardized payment system implemented in 1983 by Medicare to help manage health care reimbursement whereby the incentive for hospitals to deliver unnecessary care is eliminated. Under PPS, hospitals are paid fixed amounts based on the principal diagnosis for each Medicare hospital stay. In some cases, the Medicare payments will be more than the actual cost of providing services for that stay; in other cases, the payment will be less than the hospital's actual cost. |
| Provider | A person, organization or institution certified to provide health or medical care services. This includes, but is not limited to, hospital, health care delivery systems, long-term care facilities, physicians, and suppliers of drugs or durable medical equipment. |
| Railroad Retirement | Persons who worked for a railroad company are entitled to their benefits at retirement (includes Medicare). |
| Reasonable and Necessary Care | The amount and type of health services generally accepted by the health community as being required for the treatment of a specific disease or illness. |
| Reconsideration (or Review) | The first step in the Medicare Part A appeal process in which the beneficiary sends a written request to the intermediary showing his or her disagreement with the Part A payment allowed for a claim and asking that the payment decision be reviewed. |
| Regional Home Health Intermediary (RHHI) | Private health insurance company under contract with the Centers for Medicare & Medicaid Services (CMS) to handle claims processing for home health and hospice claims. There are currently eight RHHIs serving specific geographic areas. |
| Review (or Reconsideration) | The first step in the Medicare Part B appeal processing which the beneficiary sends a written request to the carrier showing his or her disagreement with the Part B payment allowed for a claim and asking that the payment decision be reviewed. |
| Secondary Payer | A payer of medical benefits whose payments cannot be made until another, primary party has processed the claim and issued a claim determination. |
| Skilled Nursing Care | Care which can only be proved by or under the supervision of licensed nursing personnel. Skilled rehabilitation care must be provided or supervised by licensed therapy personnel. All care is under the general direction of a physician and necessary on a daily basis. Therapy that is needed only occasionally, such as twice a week, or where the skilled services that are needed do not required inpatient care, do no qualify as skilled level of care. |
| Skilled Nursing Facility (SNF) | A Medicare approved skilled nursing facility which is staffed and equipped to furnish skilled rehabilitation services and other important related health services for which Medicare pays benefits. |
| Specified Low-Income Medicare Beneficiary (SLMB) | A federally required program where state much pay the Medicare Part B premium based on income, resources, and assets. |
| Speech Therapy | The study, examination, and treatment of defects and diseases of the voice, speech, spoken and written language. |
| Supplemental Security Income (SSI) | A federal program that pays monthly checks to people in need who are 65 years or older and to people in need at any age who are blind and disabled. The purpose of the program is to provide sufficient resources so that any one who is 65 or blind or disabled can have a basic monthly income. Eligibility is based on income and assets. |
| Suppliers | Persons or organizations, other than physicians or health care facilities, that furnish medical equipment or services, such as ambulance firms, laboratories and equipment rental outlets. |
| Third Party Liability | A party other than the beneficiary who is responsible for payment of part or all of a specific Medicare claim. Medicare supplemental insurance (Medigap) coverage is one example. |
| Title XVIII | That portion of the Social Security Act which clearly defines the provisions of Medicare. |
| Title XIX | That portion of the Social Security Act which established that Social Security funds will be used to fund, on a federal/state cost sharing basis, a general medical assistance program, known as Medicaid. |
| Unbundling | Charging separately for items that should be billed together as a package or bundle. |
| Upcoding | Billing for a higher dollar service than what was provided. |
| Visit | An encounter between a patient and a health care professional which requires either the patient to travel from his home to the professional's usual place of practice (an office visit), or for the doctor or other health care provider to see the patient in the hospital, skilled nursing facility, or in the patient's home. Doctors' services can be covered in any of these settings under Medicare. |