IHCP Glossary

0-9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

1115(a)-Section of the Social Security Act that allows states to waive provisions of Medicaid law to test new concepts that are congruent with the goals of the Medicaid program. Radical, system-wide changes are possible under this provision. Waivers must be approved by the Centers for Medicare & Medicaid Services.

11971 or 8A-DFC Form 8, formerly DPW Form 8A (State Form 11971) - Notice to Provider of Recipient Deductible. Used to relay recipient spend-down information to providers.

1261A Form-State Form 44697, OMPP (Division of Family and Children State Form) 1261A, Certification - Plan of Care for Inpatient Psychiatric Hospital Services Determination of Medicaid Eligibility. Used to provide written certification of need for inpatient psychiatric admissions. Hospitals must submit this form to Medicaid's medical policy contractor for admissions to private psychiatric hospitals. State-owned psychiatric facilities must submit this form to the MMRT. The form is reviewed by the Medicaid policy contractor or the MMRT to determine appropriateness of the inpatient stay.

1500 or CMS-1500-CMS-approved standard health insurance claim form used by participating IHCP providers to bill medical and medically related or professional services. Formerly referred to as HCFA-1500. The electronic transaction equivalent is the 837 P.

1902(a)(1)-Section of the Social Security Act that requires state Medicaid programs be in effect "in all political subdivisions of the state."

1902(a)(10)-Section of the Social Security Act that requires state Medicaid programs to provide people with services that are comparable in amount, duration, and scope.

1902(a)(23)-Section of the Social Security Act that requires state Medicaid programs to ensure that clients have the freedom to choose any qualified provider to deliver a covered service.

1902(r)(2)-Section of the Social Security Act that allows states, when determining Medicaid eligibility, to use more liberal income and resource methodologies than those used to determine Social Security Income eligibility.

1903(m)-Section of the Social Security Act that allows state Medicaid programs to develop risk contracts with health maintenance organizations or comparable entities.

1915(a)-Section of the Social Security Act that states requirements for Medicaid.

1915(b)-Section of the Social Security Act that allows states to waive Freedom of Choice. States may require that beneficiaries enroll in HMOs or other managed care programs, or select physicians to serve as their primary care case managers. Waivers must be approved by the CMS.

1915(c)-Section of the Social Security Act that allows states to waive various Medicaid requirements to establish alternative, community-based services for individuals who qualify to receive services in intermediate care facilities for the mentally retarded (ICFs/MR), nursing facilities or institutions for mental disease, or inpatient hospitals. Waivers must be approved by the CMS.

1915(c)(7)(b)-Section of the Social Security Act that allows states to waive Medicaid requirements to establish alternative, community-based services for individuals with developmental disabilities who are placed in nursing facilities but require specialized services. Waivers must be approved by the CMS.

1929-Section of the Social Security Act that allows states to provide a broad range of home and community care to functionally disabled individuals as an optional state plan benefit. The option can serve only people 65 or older. In Indiana, individuals of any age may qualify to receive personal care services through Section 1929 if they meet the state's functional disability test and financial eligibility criteria.

270-The X12 Health Care Eligibility and Benefit Inquiry transaction. The Eligibility and Benefit transactions are designed so that those who submit inquiries can: a) determine whether an information source, such as payer, employer, or HMO, has a particular subscriber or dependent on file; and b) view healthcare eligibility or benefit information about that subscriber and his or her dependents. The data available through these transaction sets is used to verify an individual's eligibility and benefits but cannot provide a history of benefit use. The information source may provide information about other organizations that may have third-party liability for coordination of benefits. Version 4010 of this transaction has been included in the HIPAA mandates.

271-The X12 Health Care Eligibility and Benefit Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

276-The X12 Health Care Claims Status Inquiry transaction - Claim Status Request/Claim Status Response. The 276 transaction set is used to request the current status of claims. The 277 transaction set can be used to: a) solicit response to a healthcare claim status request (276); b) provide notification about healthcare claim status, including front-end acknowledgments; or c) request additional information about a healthcare claim. The 276 is used only in conjunction with the 277 Health Care Claim Status Response. Version 4010 of this transaction has been included in the HIPAA mandates.

277-The X12 Health Care Claim Status Response transaction - Unsolicited Claim Status. A transaction set that can be used to transmit an unsolicited notification about a healthcare claim status. Version 4010 of this transaction has been included in the HIPAA mandates. This transaction is also expected to be part of the HIPAA claim attachments standard.

278-The X12 Prior Authorization Review Request and Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

450B Form-State Form 38143 (R5/6-93)/Form 450B/PASRR2A - Physician Certification for Long Term Care Services. Completed by the physician to obtain medical information from the attending physician and determine medical needs for level-of-care for the following:

Admission to and Medicaid reimbursement for nursing facilities
Medicaid reimbursement for intermediate care facilities for the mentally retarded/developmentally disabled
Medicaid home- and community-based services waiver programs
State-funded Community and Home Option to Institutional Care for the Elderly and Disabled program

This form, generally known as the form 450B, may be used by other programs under the Division of Disability, Aging, and Rehabilitative Services.

5 Whys-An exercise of asking five times why a failure occurred to identify the root cause or causes of a problem.

590 Program-A State health coverage program for residents of state-owned facilities under the direction of the Indiana Family and Social Services Administration, the Division of Mental Health and Addiction, the Indiana State Department of Health, and the Indiana Department of Correction.

Members enrolled in the 590 program are eligible for the full array of benefits covered by the IHCP. Services are reimbursed per claim by the program when the claim total is greater than $150. If the claim total is less than $150, the 590 facility is responsible for the cost of services. All services totaling $500 or more require prior authorization. All services provided on site at the facility are the financial responsibility of the facility.

7748-State Form 7748, Medicaid Financial Report used for cost reporting.

820-The X12 MCE Capitation Payment transaction - Premium Payment. Can be used by premium remitters to report premium payment remittance information, as well as premium payments to premium receivers. The premium remitter can be: a) an employer-operated internal department or an outside agency which performs payroll processing on behalf of an employer; b) a government agency paying healthcare premiums; or c) an employer paying group premiums. The premium receiver can be either an insurance company, a government agency, or a healthcare organization. The 820 can be sent from the premium remitter to the premium receiver directly through a value-added network or through a financial institution using an Automated Clearing House Network to facilitate both the remittance and dollars movement. Version 4010 of this transaction has been included in the HIPAA mandates.

834-The X12 Benefit Enrollment and Maintenance transaction -Enrollment/Maintenance. Used to transfer enrollment information from the sponsor (the party that ultimately pays for the coverage, benefit, or policy) to a payer - the party that pays claims or administers the insurance coverage, benefit, or product. Version 4010 of this transaction has been included in the HIPAA mandates.

835-The X12 Health Care Claim Payment and Remittance Advice transaction - Payment Advice. Contains information about the payee, payer, amount, and any identifying information of the payment. In addition, the 835 can authorize a payee to have a Depository Financial Institution take funds from the payer's account and transfer those funds to the payee's account. Version 4010 of this transaction has been included in the HIPAA mandates.

837-The X12 Health Care Claim or Encounter transaction - Dental/Professional/Institutional Claim. Intended to originate with the healthcare provider or the healthcare provider's designated agent. The 837 provides all necessary information to allow the destination payer to at least begin to adjudicate the claim. The 837 coordinates with a variety of other transactions, including the Claim Status (277), Remittance Advice (835), and Functional Acknowledgment (997). Version 4010 of this transaction has been included in the HIPAA mandates.

8A or 11971-DFC Form 8, formerly DPW Form 8A (State Form 11971) - Notice to Provider of Recipient Deductible. Used to relay recipient spend-down information to providers.

997-X12 Functional Acknowledgement. Used to report HIPAA compliance status for batch EDI transactions submitted electronically. The 997, generated by the receiver of an 837, notifies the sender that the acknowledged transaction has been accepted, rejected, accepted with errors, or partially accepted. This is an X12 transaction mandated by HIPAA regulations.

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A&D (Aged and Disabled) [waiver]-Also known as AD.

A/R (accounts receivable)-Money owed to the State by a provider, beneficiary, insurance company, drug manufacturer, and so forth.

AAA (Area Agency on Aging)-This agency is a significant element in Home and Community-Based Services (HCBS) Waiver Programs. Currently known as Aging and Disability Resource Center (ADRC).

AAAX Drugs (anti-anxiety, antidepressant, antipsychotic, and cross-indicated drugs)-A list of drugs that by state law are considered preferred products by the preferred drug list. These drugs are subject to utilization edits, Prospective Drug Utilization Review (ProDUR) edits and 34-day maintenance drug requirements.

additional function indicator (AFI)-Provides additional member-related health information. Example: Member is a smoker.

AB (Aid to the Blind)-A classification or category of members eligible for benefits under the IHCP.

abandoned call-A call is considered abandoned if the caller is connected to the system but hangs up before being connected with an agent or informational announcement. Also known as a lost call.

Abuse-Payment for items or services that are billed by mistake by providers, but should not be paid for by Medicaid. This is not the same as fraud.

Accelerated Submission And Processing (ASAP)-PC software developed to allow faster electronic claim submission and processing. This product is used to submit medical claims. The claims can be transmitted from the provider's office directly (via telephone lines) to a host computer or copied to a disk and mailed to the Medicaid agency for processing.

Access Control Facility (ACF)-Mainframe security for MMIS. ACF2 for CICS includes security by individual, location, files, and fields.

Access Control Facility/Multiple Virtual Storage (MVS OS)-A Security Extension to the IBM Multiple Virtual Storage Operating System.

accidental death and dismemberment benefit-A lump sum payment made when an insured dies as the direct result of an accident; or when an insured accidentally loses a limb or his or her sight.

accommodation-A hospital room with one or more beds.

accommodation charge-A charge billed on inpatient hospital claims for bed, board, and nursing care (revenue codes 100-219).

accounts receivable (A/R)-Money owed to the State by a provider, beneficiary, insurance company, drug manufacturer, and so forth.

accretion-An addition to a file or list, such as the monthly additions to the Medicare Buy-In List. A process that occurs when a beneficiary is eligible for coverage under both Medicaid and Medicare. Medicaid pays the beneficiary's Medicare premium, thus buying into the Medicare Program.

ACF (Access Control Facility)-Mainframe security for MMIS. ACF2 for CICS includes security by individual, location, files, and fields.

ACN (attachment control number)-A unique code assigned for an attachment of an electronically submitted claim.

ACS (Affiliated Computer Services)-The contractor with IHCP for Clinical Services for Pharmacy and Drug Rebate; also the IHCP contractor for the Healthy Indiana Plan - Enhanced Service Plan program for non-pharmacy services.

action plan-Specific method or process to achieve the results called for by one or more objectives. May be a simpler version of a project plan.

activities of daily living (ADL)-Basic self-care activities engaged in by adults to maintain health and social acceptability, such as bathing, dressing, mobility, toileting, eating, and transferring.

actual charge-A charge made by a physician or other supplier of medical services and used in the determination of reasonable charges.

AD (aged and disabled) [waiver]-Also known as A&D.

ad hoc report-A user-configured query to obtain data; a nonstandard report requested by a customer or vendor that is not part of any routine reporting.

ad hoc request-A request to provide nonproduction support. This support may be in the form of one-time updates to production files or the creation of specific one-time or as-needed reports.

ADA (American Dental Association)-The national professional association for dentists.

ADA (Americans with Disabilities Act)-Public Law 101-336. Prohibits discrimination and ensures equal opportunity for persons with disabilities in employment, state and local government services, public accommodations, commercial facilities, and transportation. It also mandates the establishment of telecommunications device for the deaf (TDD)/telephone relay services.

ADA 1999/2000-American Dental Association Claim Form. This form was replaced by the ADA 2006 on April 15, 2007.

ADA 2006-American Dental Association Claim Form effective April 15, 2007. Also referred to as J400D. A common format for reporting dental services to a patient's dental benefit plan.

ADAP (AIDS Drug Assistance Program)-Helps people who have tested positive for HIV. The program allows these people to access approved drugs through participating pharmacies. Funds may also be used to purchase health insurance for eligible clients. Amendments to the Ryan White CARE Act in October 2000 added language allowing ADAP funds to be used to pay for services that enhance access, adherence, and monitoring of drug treatments. The program is funded through Title II of the CARE Act, which provides grants to states and territories.

add-on codes-Supplemental procedures that are commonly carried out in addition to the primary procedure performed.

adjudicate-To process a claim to pay or deny.

adjudication cycle-The daily or weekly claim process leading to the point where a decision is made to pay, deny, or suspend a claim.

adjusted claim-A previously paid claim that has undergone data modification. The need to adjust a claim may result from data entry errors, billing errors, file updates, or program logic modifications. (See adjustment.)

Adjustment-A change made to a previously processed claim that has not been denied. This change rectifies a provider's account by correcting underpayments, overpayments, or claim history. Adjustments also include capitation correction of a payment or credit to capitation. The provider, contractor, or State can submit adjustments.

adjustment processing-A batch process that sends a file of adjustment request records to the Financial Subsystem for incorporation into the claims processing cycle.

adjustment reason code (ARC)-National code that explains modification to a claim. Adjustment reason codes specify why the initial adjustment took place, whereas the secondary adjustment reason indicates the second adjustment to a claim. These codes are also known as the primary reason and the secondary adjustment reason.

adjustment recoupments-Recoupments set up by the adjustments staff to reclaim payments made in error through the adjustment process. A record of these recoupments is maintained by the Cash Control System until zero-balanced.

ADL (activities of daily living)-Basic self-care activities engaged in by adults to maintain health and social acceptability, such as bathing, dressing, mobility, toileting, eating, and transferring.

Administration Fee Listing-Monthly case management fees paid for every member actively assigned to a Medicaid Select or Care Select primary medical provider (PMP). Fee listings are mailed to the PMP each month and list members for whom the PMP is receiving administrative payment. The administrative fee for Care Select is $15; the fee for Medicaid Select is $4.

Administrative-A standard tone-dial telephone connected to the telephone system through a station line telephone interface card and assigned to a user in a user record.

administrative component-One of four case-mix components used to calculate rates. It includes allowable administrator and co-administrator services; owner's compensation (including director's fees) for patient-related services; services and supplies of a home office that are allowable and patient-related and are appropriately allocated to the nursing facility; office, and clerical staff; legal and accounting fees; advertising costs; costs of travel, telephone, license dues, and subscriptions; office supplies; working capital interest; state gross receipts taxes; utilization review costs; liability insurance; and management and other consultant fees. The other three components are: capital, direct-care, and indirect-care.

administrative fee-Monthly case management fees are paid for every member actively assigned to a Care Select primary medical provider (PMP). Fee listings are mailed to the PMP each month and list the members for whom the PMP is receiving adminstrative payment. The administrative fee for Care Select PMPs is $15.00.

administrative review (AR)-An optional, pre-appeal remedy that allows providers to present additional documentation, arguments, or both, concerning why HCP should modify or retract a proposed action. If a provider timely requests an AR, the time for filing a request for fair hearing does not run until HCP issues a letter concerning the agency's decision after the AR, setting out the new time limit for filing a request for fair hearing. Also known as administrative reconsideration.

administrative service organization (ASO)-A contract between an insurance company and a self-funded plan in which the insurance company performs only administrative services and does not assume any risk.

administrative user-A staff member who is defined within the telephone system as a user, but whose primary duties do not involve handling customer calls. Administrative users provide backup assistance for agents; overflow calls are routed to administrative users through administrative groups.

Admission-The first day on which a patient is furnished inpatient hospital or extended care services by a qualified provider.

ADRC (Aging and Disability Resource Center)-This agency is a significant element in Home and Community-Based Services (HCBS) Waiver Programs. Formerly known as Area Agency on Aging (AAA).

adult care home-A program that pays for room, board, and all routine services and supplies required by residents in nursing facilities, nursing facilities for mental health, and intermediate care facilities for the mentally retarded. Includes nursing facilities, intermediate personal care homes, one- to five-bed adult care homes, and boarding care homes.

advance planning document (APD)-A planning guide the federal government requires when a state requests 90 percent funding for design, development, and implementation or proposed enhancement of an MMIS.

Advanced Information Management (AIM)-Indiana's current MMIS, referred to as IndianaAIM. See IndianaAIM, MMIS.

Advanced Registered Nurse Practitioner-A registered nurse with specialized training in high-level nursing skills.

ADVANTAGE Health Solutions^SM-State-contracted vendor. Use this version of the name when referring to ADVANTAGE. Write as shown for first usage; service mark (SM ) is not required for subsequent uses.

ADVANTAGE Health Solutions^SM - CMO-State-contracted vendor that performs Care Select - care management organization activities that include care management, prior authorization, restricted cards, and management of physical, behavioral, and transportation services for its members. Use this version of the name when referring to the Care Select CMO vendor for prior authorization and restricted card processes. Write as shown for first usage; service mark (SM ) is not required for subsequent uses.

ADVANTAGE Health Solutions^SM - FFS-State-contracted vendor that performs the prior authorization and restricted card processes for Traditional Medicaid - Fee-for-Service (FFS) and carve-out services for Hoosier Healthwise - risk-based managed care (RBMC). Use this version of the name when referring to the Traditional Medicaid prior authorization vendor. Write as shown for first usage; service mark (SM ) is not required for subsequent uses.

AFDC (Aid to Families with Dependent Children)-A welfare program funded by federal and state dollars that provides cash and Medicaid benefits to families with at least one child where one or both parents are absent, deceased, or incapacitated. This term has been replaced by Temporary Assistance for Needy Families (TANF); however, AFDC rules must still be used to establish Medicaid eligibility.

Affiliated Computer Services (ACS)-The contractor with IHCP for Clinical Services for Pharmacy and Drug Rebate; also the IHCP contractor for the Healthy Indiana Plan - Enhanced Service Plan program for nonpharmacy services.

AFI (additional function indicator)-Provides additional member-related health information. Example: Member is a smoker.

after auditing allowed amount-The amount allowed for the claim based on appropriate pricing methodology and number of Medicaid allowed units. This is the fee-for-service allowance.

after auditing units-The number of units allowed after the claim has been audited against history (encounter data and fee-for-service) and medical policy criteria. This is the number of Medicaid allowed units.

AGCCS (Allergy Group Code Cross Sensitive)-The cross-sensitive group code provided by First DataBank.

Aged and Disabled (A&D) [waiver]-Also known as AD.

Aged and Medicare-Related Coverage Group-Needy individuals 65 years old or older who have been designated by the Department of Human Services (DHS) for medical assistance; or members under any other category who are entitled to benefits under Medicare.

aggregate-A collection of data at the summary level.

aggregation codes-System codes that classify the providers rendering services to members.

Aging and Disability Resource Center (ADRC)-This agency is a significant element in Home and Community-Based Services (HCBS) Waiver Programs. Formerly known as Area Agency on Aging (AAA).

aid category-A designation within the State Social Services Department under which a person may be eligible for public assistance and medical assistance (Medicaid).

aid code-A designation of the type of benefits for which a Medicaid beneficiary is eligible.

Aid to Families with Dependent Children (AFDC)-A welfare program funded by federal and state dollars that provides cash and Medicaid benefits to families with at least one child where one or both parents are absent, deceased, or incapacitated. This term has been replaced by Temporary Assistance for Needy Families (TANF); however, AFDC rules must still be used to establish Medicaid eligibility.

Aid to the Blind (AB)-A classification or category of members eligible for benefits under the IHCP.

AIDS Drug Assistance Program (ADAP)-Helps people who have tested positive for HIV. The program allows these people to access approved drugs through participating pharmacies. Funds may also be used to purchase health insurance for eligible clients. Amendments to the Ryan White CARE Act in October 2000 added language allowing ADAP funds to be used to pay for services that enhance access, adherence, and monitoring of drug treatments. The program is funded through Title II of the CARE Act, which provides grants to states and territories.

AIM (Advanced Information Management)-Indiana's current MMIS, referred to as IndianaAIM. See IndianaAIM, MMIS.

alerts-A message for supervisors or system managers; may include error messages and emergency warnings.

AllInternetNow^®-Serves as a representative of Internet service providers in the United States and Canada. An AllInternetNow customized Web site connection is available to allow IHCP trading partners to view individual ISP options. The AllInternetNow search service is free of charge, and trading partners are under no obligation to choose an ISP through the service.

allowable costs-The maximum dollar amount assigned for a particular procedure, based on various pricing mechanisms. Medicaid reimburses hospitals for some, but not all, costs. Excluded costs include noncovered services, luxury accommodations, and unnecessary and unreasonable costs.

allowed amount-Either the amount billed by a provider for a medical service, the department's established fee, or the reasonable charge, whichever is the lesser.

ALOS (average length of stay)-The mean number of days of care for inpatient hospitalizations for residents of a given region. Calculated by dividing the total number of hospital days for residents of a given region for the fiscal year by the total number of inpatient hospital separations during the same period. Zero-day stays for surgical outpatient care are not included in the calculation. ALOS usually refers to hospital inpatient stays, but it may also refer to mental health and personal care home residents.

alpha-Data composed of letters only.

alphanumeric-Data composed of numbers, letters, and special characters.

alternate processing site-The location of HP computer hardware and networking services that would be used to recover Title XIX information processing after a disaster. Also called the recovery site.

alternate work site-A temporary location where HP personnel from the Indiana Title XIX account may work if the normal work location becomes uninhabitable. As documented in the contract, all Indiana Solution Centre sites in Indiana serve as alternate work sites for the account.

ambulance service supplier-A person, firm, or institution approved for and participating in Medicare as an air, ground, or host ambulance service supplier or provider.

American Dental Association (ADA)-The national professional association for dentists.

American National Standards Institute (ANSI)-Voluntary organization founded in 1918 that creates standards for several industries, including the computer industry. In computer programming, ANSI most often denotes the standard versions of C, FORTRAN, COBOL, or other programming languages. ANSI-standard escape sequences control computer screens, whereas the ANSI extended character set used in Microsoft Windows products includes all the ASCII characters (see American Standard Code for Information Interchange.)

American Standard Code for Information Interchange (ASCII)-The most popular coding method used by small computers for converting letters, numbers, punctuation, and control codes into digital form. Once defined, ASCII characters can be recognized and understood by other computers and by communications devices. ASCII represents characters, numbers, punctuation marks, or signals in seven on-off bits. Capital "C," for example, is 1000011, while "3" is 0110011. This compatible coding allows all PCs to talk to each other, as long as they use compatible modems or null modem cables, and transmit and receive at the same speed.

Americans with Disabilities Act (ADA)-Public Law 101-336. Prohibits discrimination and ensures equal opportunity for persons with disabilities in employment, state and local government services, public accommodations, commercial facilities, and transportation. It also mandates the establishment of telecommunications device for the deaf (TDD)/telephone relay services.

amount, duration, and scope-The way an IHCP benefit is defined and limited in a state's Medicaid plan. Each state defines these parameters, so state Medicaid plans vary in what is actually covered.

AMP (average manufacturer price)-With respect to a covered outpatient drug of the labeler (manufacturer), the AMP is the average quarterly unit price wholesalers pay to labelers for the drug in the United States. Refers to drugs distributed to the retail pharmacy class of trade (excluding direct sales to hospitals, health maintenance organizations, and wholesalers, where the drug is relabeled under that distributor's National Drug Code number).

analysis-Examination of facts and data to identify gaps between actual and desired organizational performance.

analytical thinking-Breaking down a problem or situation into discrete parts to understand how each part contributes to the whole.

ancillary charge-A charge used only in institutional claims for any item except hospital and doctor fees (examples include drug, laboratory, and x-ray charges).

ANSI (American National Standards Institute)-Voluntary organization founded in 1918 that creates standards for several industries, including the computer industry. In computer programming, ANSI most often denotes the standard versions of C, FORTRAN, COBOL, or other programming languages. ANSI-standard escape sequences control computer screens, whereas the ANSI extended character set used in Microsoft Windows products includes all the ASCII characters. (See American Standard Code for Information Interchange.)

Anthem-A managed care organization responsible for statewide coverage of Hoosier Healthwise participants.

Anthem Blue Cross and Blue Shield-State-contracted insurer for the Healthy Indiana Plan program.

anti-anxiety, antidepressant, antipsychotic, and cross-indicated drugs (AAAX Drugs)-A list of drugs that by state law are considered preferred products by the preferred drug list. These drugs are subject to utilization edits, Prospective Drug Utilization Review (ProDUR) edits and 34-day maintenance drug requirements.

APD (advance planning document)-A planning guide the federal government requires when a state requests 90 percent funding for design, development, and implementation or proposed enhancement of an MMIS.

appellant-Someone who appeals a decision.

approved (CR)-Change request approved by the Operational Effectiveness Team (OET) or the OMPP Governance Board (OGB).

Approved to be worked (CR)-Change request approved by the OET or OGB to be assigned resources.

ARC (adjustment reason code)-National code that explains modification to a claim. Adjustment reason codes specify why the initial adjustment took place, whereas the secondary adjustment reason indicates the second adjustment to a claim. These codes are also known as the primary reason and the secondary adjustment reason.

ARCH (Assistance to Residents in County Homes)-A state-funded program that provides medical services to residents of county nursing homes.

archive-A copy of data on disks, CD-ROM, magnetic tape, and so forth, for long-term storage and later possible access. Archived files are often compressed to save storage space.

Area Agency on Aging (AAA)-This agency is a significant element in Home and Community-Based Services (HCBS) Waiver Programs. Currently known as Aging and Disability Resource Center (ADRC).

area prevailing charge-Under Medicare Part B, the charge that, based on statistical data, would cover the customary charges made for similar services in the same locality.

as of date-Based on parameters entered, the date of the cycle run.

ASAP (Accelerated Submission and Processing)-PC software developed to allow faster electronic claim submission and processing. This product is used to submit medical claims. The claims can be transmitted from the provider's office directly (via telephone lines) to a host computer or copied to a disk and mailed to the Medicaid agency for processing.

ASCII (American Standard Code for Information Interchange)-The most popular coding method used by small computers for converting letters, numbers, punctuation, and control codes into digital form. Once defined, ASCII characters can be recognized and understood by other computers and by communications devices. ASCII represents characters, numbers, punctuation marks, or signals in seven on-off bits. Capital "C," for example, is 1000011, while "3" is 0110011. This compatible coding allows all PCs to talk to each other, as long as they use compatible modems or null modem cables, and transmit and receive at the same speed.

ASO (administrative service organization)-A contract between an insurance company and a self-funded plan in which the insurance company performs only administrative services and does not assume any risk.

assigned claim-A claim for which the service provider has agreed to accept the program's allowed charge as payment in full without recourse to the patient, except for coinsurance or deductible amounts.

assigned systems engineer, assigned SE-The systems engineer (SE), assigned by the SE manager, who actually works the issue with the subject-matter expert (SME).

assignment-When a provider accepts the maximum allowable charge offered for a given procedure under the Medicare Program, this person is said to "accept assignment." The provider has waived the right to bill the beneficiary for the difference between what Medicare pays and what the provider usually charges. The term "assignment" is not related to the administration of the Medicaid Program, except that some Medicaid agencies treat crossover claims differently depending on whether or not the provider accepts assignment.

Assistance to Residents in County Homes (ARCH)-A state-funded program that provides medical services to residents of county nursing homes.

Applications tracking number (ATN)-A unique number assigned to a provider enrollment request during Web enrollment. The documents created during web enrollment are printed by the provider and mailed to the HP provider enrollment team to be processed. The ATN is printed on the documents.

attachment-Attachments may accompany claims to provide additional claim-related information for which no field is specified on the claim form, or when the specified field is not adequate to submit the required information.

attachment control number (ACN)-A unique code assigned for an attachment of an electronically submitted claim.

Attendant Care for Independent Living-A State program for chronically ill or technologically dependent children.

attending physician-The physician providing specialized or general medical care to a member or recipient..

atypical providers-Atypical providers are professionals who do not provide healthcare as defined under the HIPAA in federal regulations (45 CFR 160.103). Taxi services, home and vehicle modifications, and respite services are examples of atypical providers reimbursed by Medicaid. Even if these atypical providers submit HIPAA transactions, they still do not meet the HIPAA definition of healthcare and therefore cannot receive National Provider Identifiers. Therefore, the Medicaid Management Information System (MMIS) must accommodate current Legacy Provider Identifier numbers for atypical providers.

AU (Autism) [waiver]-A waiver program administered by the Division of Disabilities and Rehabilitative Services (Indiana) for autistic IHCP members.

audit-A limitation based on comparing the current claim with claims history - for example, duplicate audits, which compare the current claim against other claims previously processed to see if the provider has already been paid for the service.

Audits applied to specific procedures, diagnoses, or other data elements after editing and validation of the claim ensure that claim payments are uniform and consistent.

Note: "Audit" is often used interchangeably with "edit." At one time, the word audit had the connotation of a qualitative versus a quantitative validation. For example, utilization review criteria edits were called audits because they did more than validate the presence of data; they determined if the data was allowed by examining claims in history. In other words, audit is a more sophisticated type of data validation.

A formal or periodic checking of accounts, such as a drug audit or a nursing home audit.

audit adjustment-Adjustments initiated by the State after a formal examination or verification of a provider's financial records.

auditing contractor-The entity under contract with the Office of Medicaid Policy and Planning (OMPP) to conduct audits of long-term care facilities or other functions and activities, as designated by the OMPP.

AUT (Autism) [waiver]-A waiver program administered by the Division of Disabilities and Rehabilitative Services (Indiana) for autistic IHCP members.

authentication-A query method that ensures that both the sender and receiver of an electronic message are valid, and are authorized to transmit and receive messages.

Authorization for Member Liability Deviation (C519)-Generated by the Medicaid caseworker. Applies only to nursing home residents.

authorization testing-Testing of a submitter's ability to exchange data in a valid format for processing by the MMIS.

autism (AUT? or AU?) [waiver]-A waiver program administered by the Division of Disabilities and Rehabilitative Services (Indiana) for autistic IHCP members.

auto assignment-An IndianaAIM process that designates a managed care provider for a managed care member if the member does not select a provider within a specified time frame.

Automated Voice Response (AVR)-Computerized voice-response system used by providers to obtain pertinent information by telephone, including member eligibility, benefit limitation, and (PA) for ICHP participants.

automatic recoupment-Occurs when an account receivable (A/R) with a credit balance has recoupments applied to it by adjustments or new-day claims. Money is recouped only through the payment process, which is automatic and cannot be posted online with a refund.

Avaya Call Management System-Avaya Definity 75 G3r-V9 telephone system. Provides information and management tools to help monitor and analyze the performance of the call center.

average length of stay (ALOS)-The mean number of days of care for inpatient hospitalizations for residents of a given region. Calculated by dividing the total number of hospital days for residents of a given region for the fiscal year by the total number of inpatient hospital separations during the same period. Zero-day stays for surgical outpatient care are not included in the calculation. ALOS usually refers to hospital inpatient stays, but it may also refer to mental health and personal care home residents.

average manufacturer price (AMP)-With respect to a covered outpatient drug of the labeler (manufacturer), the AMP is the average quarterly unit price wholesalers pay to labelers for the drug in the United States. Refers to drugs distributed to the retail pharmacy class of trade (excluding direct sales to hospitals, health maintenance organizations, and wholesalers, where the drug is relabeled under that distributor's National Drug Code number).

average wholesale price (AWP)-A value derived at by the official compendia for the basis of product pricing.

AVR (Automated Voice Response)-Computerized voice-response system used by providers to obtain pertinent information by telephone, including member eligibility, benefit limitation, and (PA) for ICHP participants.

AWP (average wholesale price)-A value derived at by the official compendia for the basis of product pricing.

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BA (benefit advocate)-Representative of a managed care organization who helps members choose his or her PMP and informs members about available services.

BABES-Not-for-profit stores where pregnant women and new mothers can shop for necessities for newborns.

backup-Duplicate copy of data placed in a separate, safe place - in electronic storage, on a tape, on a disk, in a vault - to guard against total loss in the event the original data somehow becomes inaccessible. Generally for short-term safety. Contrast with archive, which is a filed-away record of data meant to be maintained a long time, in the event of future reference.

Balanced Budget Act of 1997 or Balanced Budget Act (BBA)-Federal legislation (Federal Public Law 105-33) enacted in 1997 that represents the most significant changes in the Medicaid/Medicare Programs since their inception. The Balanced Budget Act created a new Title XXI, the State CHIP; gave beneficiaries certain rights related to managed care enrollment and disenrollment; and provided the state with an option to use managed care. It also required that an MMIS be compatible with Medicare claims processing and must, after January 1, 1999, transmit data in a format consistent with the Medicaid Statistical Information System (MSIS).

bank identification number (BIN)-A unique number linked to a bank or card issuer and that is used for network routing.

banner page-Important information about IHCP program changes and upcoming training sent weekly to providers with Remittance Advice (RA).

baseline measurement-The basis against which change is measured.

Batch-A set of claims. Paper claims are batched by invoice type, such as UB-04, CMS-1500, pharmacy, adjustments, and so forth. The number of claims in a paper batch may vary from one to 99. Electronic batches have no claim ceiling, but must contain at least 25 claims. Claims are batched to control the quality and quantity of claims entered into the system. Batching supports the assignment of unique sets of numbers to specific sets of claims. There are batch number ranges for certain batch types: electronic media claims (EMCs), adjustments, credits, POS transactions, and so forth.

batch cycle-A weekly process that adjudicates claims, pays providers, produces remittance advices (RAs), and updates claims histories and accounts receivable (A/Rs), along with many other nonfinancial functions. Batch cycles are scheduled by the health care administrator (HCA), and processing from all subsystems and claim adjudication is done at this time.

batch processing-One of the noninteractive computer processes used in the MMIS. In batch processing, the user gives the computer a "batch" of information; the computer then processes it as a whole. Batch processing contrasts with interactive processing, in which the user communicates with the computer by means of a workstation while the program is running.

batch request-A batch claim submission does not require immediate processing. The requester does not wait for the request to be completed. Response reports are sent back to requesters approximately two hours after the batch is received.

BBS (bulletin board system)-In Indiana, a BBS is used for IHCP facilities to send assessment data and receive validation reports. A BBS consists of a computer running specialized software that allows information to be exchanged electronically via modem. Multiple users can be logged on at one time, each with a private session.

BC2-An untimely record not transmitted within 113 days.

An End of Therapy record not transmitted in a timely manner per regulations.

BCP (Business Continuity Plan)-The documented set of practices designed to mitigate risks and ensure the availability of essential account services while providing for the safety and welfare of employees during a disaster. The Business Continuity Plan has three primary components - crisis management, disaster recovery, and business resumption.

bedhold-When an IHCP resident is admitted to a hospital, the resident's bed at a nursing facility may be "held" at half the IHCP rate; IHCP reimbursement to the facility continues. A nursing facility bed may be held for a maximum of 15 days per hospital admission.

before auditing allowed amount-The amount allowed for the claim based on appropriate pricing methodology and number of billed units.

before auditing units-The number of units allowed before auditing the claim against history and medical policy criteria. This equates to billed number of units.

behavioral healthcare-Assessment and treatment of mental and psychoactive disorders.

benchmarking-Improvement process in which a company measures its performance against that of best-in-class companies, determines how those companies achieved their performance levels, and uses the information to improve its own performance. Subjects that can be benchmarked include strategies, operations, processes, and procedures.

BENDEX (Beneficiary and Earnings Data Exchange)-A file containing data from the Health Care Financing Administration or CMS regarding persons receiving Medicaid benefits from the Social Security Administration (SSA).

beneficiary-Indiana - One who benefits from a program. Most commonly used to refer to people enrolled in the Medicare program.

Beneficiary and Earnings Data Exchange (BENDEX)-A file containing data from the Health Care Financing Administration or CMS regarding persons receiving Medicaid benefits from the Social Security Administration (SSA).

beneficiary billed claim-A process for reducing a beneficiary's spend-down amount by charges for medically necessary services that will not be billed directly to the MMIS by Medicaid providers.

beneficiary data sheet-A report used to describe the claim history of individual beneficiaries.

Beneficiary Eligibility Verification System-An online system provided by the fiscal agent to determine beneficiary eligibility. The system is accessible by providers with PCs, modems, and any off-the-shelf communications software.

Beneficiary Master File-Contains multiple types of records, including Medicare Record, LTC Record, Managed Care Record, Recipient Record, Recipient Resource Record, and Audit Record.

benefit-A schedule of healthcare coverage that an eligible participant in the IHCP receives for the treatment of illness, injury, or other conditions allowed by the State.

benefit advocate (BA)-Representative of a managed care organization who helps members choose his or her PMP and informs members about available services.

benefit level-Limit or degree of services a person is entitled to receive, based on the person's contract with a health plan or insurer.

benefit period-The period of time, usually one year, that a health plan will pay for covered benefits. (Benefit periods to not always reflect a calendar year.)

benefit plan-A group of covered services (benefits) that is granted to an eligible beneficiary.

best price-With respect to single-source and innovator multiple-source drugs, "best price" refers to the lowest price at which the labeler (manufacturer) sells the covered outpatient drug to any purchaser in the United States, in any pricing structure (including capitated payments), in the same quarter for which the average manufacturer price is computed. Best price includes prices to wholesalers, retailers, nonprofit entities, or governmental entities within the states (excluding depot prices and single-award contract prices of any agency of the federal government). Federal Supply Schedule prices are included in the calculation of the best price.

The best price also includes cash discounts, free goods, volume discounts, and rebates (other than rebates under Section 1927 of the Social Security Act).

Best price is determined on a unit basis, without regard to special packaging, labeling, or identifiers on the dosage form, product, or package. It does not take into account prices that are nominal in amount. For bundled sales, the allocation of the discount is proportionate to the dollar value of the units of each drug sold under the bundled arrangement. The best price for a quarter is adjusted by the labeler if cumulative discounts, rebates, or other arrangements subsequently adjust the price.

bidder-Any corporation, company, organization, or individual that responds to a request for proposal (RFP) or request for services (RFS).

bill-A statement of charges for medical services, the submitted claim document, or the electronic media claims (EMC) record; another term for claim or invoice. A bill may request payment for one or more performed services.

billable hour-At least 50 but not more than 60 minutes of time expended by a contractor performing maintenance and modifications of MMIS, as well as other activities authorized by the FSSA.

billed amount-The dollar figure requested for payment by a provider for a service rendered.

Biller Summary Report (BSR)-The IHCP proprietary report created to display the pre-adjudication status of batch claim files submitted electronically.

billing cycle-Indiana currently submits billing claims on a monthly basis, in accordance with the existing federal requirements.

billing provider-The party responsible for submitting to the department the bills for services rendered to IHCP members.

billing service-An entity under contract with a provider that prepares billings on behalf of the provider for submission to payers.

BIN (bank identification number)-A unique number linked to a bank or card issuer and that is used for network routing.

block-Specific area on a claim or worksheet containing claim information.

Blue Book-The American Druggist Blue Book, used as a reference in pricing drug products.

An obsolete term for the drug file updating service that is now published by the Hearst Corporation's First DataBank. The First DataBank information is sold as a service to agencies processing drug claims. The data is used to update drug records with current prices and product information (the American Druggist Blue Book, which is used as a reference in pricing drug products).

BMN (brand medically necessary)-Under certain conditions, physicians can override the mandatory generic substitution rule if they write "brand medically necessary" on a prescription. The pharmacy enters a dispense-as-written DAW value 06 on the claim. The claim process will verify that there is no SMAC or rate MAC on file and price the drug at the lowest allowed amount.

If there is a SMAC or MAC rate on file for the product, the system will check whether there is an active product-specific BMN PA on file for the recipient. If so, the MAC/SMAC price will be disregarded in determining the reimbursement amount. If no PA is on file, the claim seeking PA will be denied.

Note: Narrow Therapeutic Indicated and the AAAX (anti-anxiety, antidepressant, antipsychotic, and cross-indicated) drugs are exempt from this PA requirement for allowing increased pricing.

Board Of Healing Arts (BOHA)-The state department that regulates and certifies healthcare providers.

BOHA (Board of Healing Arts)-The state department that regulates and certifies healthcare providers.

Boren Amendment-An amendment to the Omnibus Budget Reconciliation Act 90 (P.O. 96-499) which repealed the requirement that states follow Medicare principles in reimbursing hospitals, nursing facilities (NFs), and intermediate care facilities for the mentally retarded under the IHCP. The amendment substituted language that required states to develop payment rates that were "reasonable and adequate" to meet the costs of "efficiently and economically operated" providers. Boren was intended to give states new flexibility, but it has increased successful lawsuits by providers and thus has contributed to the rising cost of Medicaid-funded institutional care.

BPM (business practice manual)-The internal user manuals of the fiscal agent.

brainstorming-Technique used to generate ideas. Each person in a team is asked to think creatively and write down as many ideas as possible. The ideas are not discussed or reviewed until after the brainstorming session, which typically follows these rules: Generate a large number of ideas. Freewheel to provoke ideas from others. Don't criticize any ideas put forth. Encourage everyone to participate. Record all the ideas. Let ideas incubate to encourage other thoughts. Have a meeting place where everyone feels comfortable. Group size should range from four to 10 individuals.

brand medically necessary (BMN)-Under certain conditions, physicians can override the mandatory generic substitution rule if they write "brand medically necessary" on a prescription. The pharmacy enters a dispense-as-written DAW value 06 on the claim. The claim process will verify that there is no SMAC or rate MAC on file and price the drug at the lowest allowed amount.

Note: Narrow Therapeutic Indicated and the AAAX (anti-anxiety, antidepressant, antipsychotic, and cross-indicated) drugs are exempt from this PA requirement for allowing increased pricing.

brand or trade name-The name of the product assigned by the manufacturer; for example, Bayer for aspirin.

brand-name drug-A term used to refer to pharmaceuticals that meet the following criteria:

The product is available from one source.
The product is under patent.

BSR (Biller Summary Report)-The IHCP proprietary report created to display the pre-adjudication status of batch claim files submitted electronically.

budgeted amount-The planned expenditures for a given time period.

bulletin-Communication to IHCP providers containing information on regulations, billing procedures, benefits, IHCP events, processing, or changes in existing benefits and procedures.

bulletin board system (BBS)-In Indiana, a BBS is used for IHCP facilities to send assessment data and receive validation reports. A BBS consists of a computer running specialized software that allows information to be exchanged electronically via modem. Multiple users can be logged on at one time, each with a private session.

bundled charges-Charges that are combined or represent a flat rate, such as capitated charges. These charges are reimbursed when there would be a specified fee for a service. For example, in a surgery, bundled charges might include supplies, surgery charges, anesthesia charges, recovery, and so forth. In contrast, if charges are unbundled, a separate fee is charged for each service.

bundled sale-The packaging of different types of drugs when a rebate or discount is offered if more than one drug type is purchased; or when the discount or rebate for the bundled sale is greater than what would have been received had the drug products been purchased separately.

bundling-The practice of including all services provided on the day of outpatient surgery on one bill. These services typically include nursing, facility use, drugs, surgical dressings, and so forth.

business associate-A term from HIPAA that applies to any person or organization (such as HP) that is not part of the covered entity's work force, but who performs a treatment, payment, or healthcare function or activity on behalf of a covered entity.

business associate agreement-Outlines how persons or organizations (such as HP) that perform treatment, payment, or healthcare functions on behalf of the IHCP must comply with the administrative, physical, and technical safeguards of HIPAA. The agreement spells out how a covered entity expects its business associate to secure electronic protected health information that the associate creates, maintains, processes, stores, or transmits on behalf of the covered entity.

business change category-A change in policy or business operation that does not require a technical (computer) resource.

Business Continuity Plan (BCP)-The documented set of practices designed to mitigate risks and ensure the availability of essential account services while providing for the safety and welfare of employees during a disaster. The Business Continuity Plan has three primary components - crisis management, disaster recovery, and business resumption.

business day-Any day the State is open for normal business.

business owner-An individual from the business area responsible for assigning a subject-matter expert to an issue, reviewing all issues assigned to the area, and ensuring that all associated tasks are completed before closing an issue - for example, banner pages, resolution manual updates, adjustments, and root-cause identification.

business practice manual (BPM)-The internal user manuals of the fiscal agent.

business process-What an organization does and how it does it. Businesses have functional processes (generating output within a single department) and cross-functional processes (generating output across several functions or departments).

Business Resumption Plan-A documented process to restore HP' technical and business services to normal functioning after a disaster.

buy-in-A procedure whereby the State pays a monthly premium to the Social Security Administration on behalf of eligible IHCP members, enrolling them in Medicare Part A or Part B, or both.

buy-in (Medicaid)-Certain disabled SSI beneficiaries who lose eligibility because of earnings are allowed to buy into Medicaid (BBA '97). See Working Healthy or TWIAA.

Buy-In Data Maintenance-Medicaid beneficiaries who are entitled to receive Medicare benefits may have Medicare premiums paid by the State. This is known as Medicare buy-in. Automated data exchanges between HP and CMS are conducted monthly to identify, update, and resolve differences, and monitor new and ongoing Medicare buy-in cases.

The State is responsible for initiating Medicare buy-in for eligible members. Because Medicare is usually primary to the State, payment of Medicare premiums, coinsurance, and deductibles costs the State less than paying the entire cost of medical care for beneficiaries.

In addition, the State receives federal financial participation (FFP) for premiums paid on behalf of members eligible as Qualified Medicare Beneficiaries (QMB), Qualified Disabled Working Individuals (QWSI), Specified Low Income Medicare Beneficiaries (SLMB), and Cash Assistance beneficiaries - that is, members with Supplemental Security Income (SSI) and cash assistance from Temporary Assistance for Needy Families (TAF).

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C&T (Certification and Transmittal)-An Indiana State Department of Health (ISDH) document used to certify an institutional provider. The C&T is also used when a facility experiences changes to its existing business.

C519 (Authorization for Member Liability Deviation)-Generated by the Medicaid caseworker. Applies only to nursing home residents.

CAC (Clinical Advisory Committee)-The committee established by the OMPP comprising actively participating medical providers enrolled in Hoosier Healthwise. The CAC's mission is to advise the OMPP by making recommendations that support the quality, accessibility, appropriateness, and cost-effectiveness of health and medical care provided to Hoosier Healthwise members.

CAH (critical access hospital)-A freestanding hospital emergency department providing limited inpatient care, as needed, to stabilize patients before discharge or transfer to an essential access community hospital for extensive treatment.

cancel (CR)-To eliminate, erase, or delete.

cap-A limit placed on the number of certain services for which the IHCP pays for a member per calendar year, or per rolling calendar year

CAP (Corrective Action Plan) [Ancillary Application]-An application that provides access and storage for all information associated with all CAPs, enabling HP and the FSSA staff to efficiently manage the CAP process. This plan is initiated by the FSSA contract monitor and submitted to the fiscal agent whenever areas of noncompliance have not been satisfactorily resolved through the preceding CAP.

Capability Maturity Model Integration (CMMI)-Models that contain the essential elements of effective processes for one or more bodies of knowledge. These models provide guidance when developing processes, though they are not processes or process descriptions; the actual processes depend on the application domain, organization structure, size, environment, and so forth.

capital component-One of the four case-mix components used to calculate rates. It includes all remuneration to providers for capital costs; the fair rental value allowance; property taxes; property insurance; and repairs and maintenance. The other three components are: administrative, direct-care, and indirect-care.

capitation-A prospective payment method in which the OMPP pays service providers uniform amounts for healthcare services, regardless of whether enrollees actually receive the services. Providers are usually paid set fees per enrollee, per month. Used in managed-care alternatives such as health maintenance organizations, capitation separates the payment process from the claims-submission process. Encounter claims are submitted for historical data, not for payment. Also known as capitation payment or rate.

capitation indicator-A one-byte field added to the claims record to identify services paid by the MCO on a capitated basis. This indicator is for informational purposes and has no impact on encounter data processing.

capitation rate-The set of fixed fees that the OMPP pays monthly to eligible managed care organizations (MCO) for enrolled Hoosier Healthwise members. In return, providers render covered medical and health services regardless of whether enrollees received services during the month for which the fee is intended. Rates vary by eligibility category.

capitation service-Medicaid-covered service for which the contractor receives capitation payment.

CA-PRTF (Community Alternatives to Psychiatric Residential Treatment Facilities)-A program for IHCP members who qualify for treatment at a psychiatric residential treatment facility at a level of care that allows the member to receive services in the community.

CAR (claims analysis and recovery)-A unit that is responsible for reviewing claims data at the systems level to determine aberrant billing patterns. The unit also conducts payment studies based on the information found. CAR staff reviews IHCP claims reimbursement compared to existing policy and coding guidelines to identify potential overpayments. Referrals may come from other units, or they may be the result of surveillance and utilization review audits. Identified issues or referrals are then turned into CAR projects. CAR staff performs research and builds queries to support the project's focus. If, after review, CAR staff determines that a medical record is needed to verify the validity of the payment, the project will be referred to surveillance and utilization review for audit.

care management organization (CMO)-An entity that is a primary care case manager, as defined by 42 Code of Federal Regulations (CFR) 438.2.

Care Plan Index (CPI)-A weighted value assigned to beneficiaries residing in nursing facilities based on care required. The index is used to determine a provider's case mix.

Care Select-A disease management program for:

The aged, blind, and physically and mentally disabled
Members receiving adoption assistance
Wards of the court and foster children

Members select doctors to serve as their primary medical providers, who are responsible for providing or coordinating members' care. The CMOs manage the care of Care Select members through its network of primary medical providers, specialists, and other contracted healthcare providers.

The Care Select program was implemented in phases from November 2007 to June 2008.

Care Select Administrative Fee Listing-Monthly case management fees of $15 paid for every member assigned to a Care Select primary medical provider. Fee listings mailed to primary care providers each month show members for whom PMPs receive administrative payment.

CareSource-A managed care organization responsible for statewide coverage for Hoosier Healthwise participants before January 1, 2007.

CARF (Commission on Accreditation of Rehabilitation Facilities)-Reviews and grants accreditation at the request of facilities or programs, such as behavioral health organizations, aging services, medical rehabilitation facilities, and so on. CARF conducts on-site surveys and works with providers to help them meet its accreditation standards.

carrier-An organization, usually a private insurance company, that processes Medicare claims on behalf of the federal government.

MACs replace Medicare carriers and fiscal intermediaries beginning in 2005. See Medicare Administrative Contractor.

carve out-A service covered by the IHCP but excluded from capitation payment. These services are payable as FFS claims in the IHCP and are not included in the scope of care managed by MCOs.

case-A file opened at the FSSA office when an individual applies for government assistance.

case head-Head of household where a person eligible for medical assistance resides.

case management-Method to provide the health services needed by individuals through coordinated efforts to achieve optimum outcomes in a cost-effective manner.

case manager (CM)-An experienced professional (for example, nurse, doctor, or social worker) who works with clients, providers, and insurers to coordinate all services required to provide clients with medically necessary, cost-effective, and appropriate healthcare.

case mix-The different types of residents in a nursing facility, as measured by resident characteristics and service needs. The case mix is used to determine payment to the facility for resources needed to serve its different types of residents.

case number-The number assigned to each Medicaid case opened by the FSSA.

case type-A set of criteria that group claims billed for members by predefined characteristics, such as services performed, diagnosis codes, provider types, or other parameters. Case types are not exclusive and can overlap, because claims may be included in more than one case type. A code designating the type of case.

case-mix index (CMI)-A numeric score that identifies the relative resources used by a particular group of nursing facility residents. The CMI represents the average resource consumption across a population or sample.

case-mix payment-The payment to a nursing facility, per resident or per facility, based on the facility's IHCP case mix. Also used to identify a type of nursing facility payment system based on resident resource levels.

case-mix weight (index)-Each Resource Utilization Group (RUG-III) is assigned a weight, or numeric score, that reflects the predicted relative resources needed to provide care to a resident. The higher the case-mix weight, the greater the resource requirements for the IHCP resident.

cash control number (CCN)-A unique code assigned to an individual financial transaction, including all refunds or repayments, before the transaction is set up within the cash-control system. The batch range within the CCN identifies the type of refund or repayment.

cash control system-Process whereby the case unit creates and maintains records for accounts receivable, recoupments, and payouts.

cash receipt-A check returned to the State.

casualty recoveries-A collection method for recovering the amount paid for claims related to accident, trauma, and medical malpractice incidents that are first paid by the IHCP and for which a third party is liable.

Casualty Unit-Investigates casualty cases, identifies casualty-related payments, and notifies potentially liable parties of IHCP interests.

categorically needy-All individuals receiving financial assistance through the State's approved plan under Titles I, IV-A, X, XIV, and XVI of the Social Security Act, or who are in need under the State's standards for financial eligibility in such a plan.

These individuals are certified by the state welfare agency as being low income. A person is categorically needy and may receive assistance if that person's income and resources do not exceed the categorically needy maximums and the person fits into one of six categories:

Age 65
Blind
Disabled
Families with dependent children (TANF)
Pregnant
Incapacitated

category code-A designation indicating the type of benefits for which an IHCP member is eligible.

category of service (COS)-The type of service a provider renders (for example, inpatient hospital, outpatient hospital, transportation, prescribed drugs, pharmacy, hospice, physician care, family planning services, therapy, crossover, and so forth).

The category under which the financial transaction should be reported.

CCB (Change Control Board)-A group of project leaders who review (approve or deny) changes to project requirements. See change request and change order information on Project Workbook

CCF (claim correction form)-Generated by IndianaAIM and sent to the provider who submitted the claim. The CCF requests that the provider return the CCF with additional or corrected information within a certain time frame. These forms were discontinued on 9/1/09.

CCITT (Consultative Committee on International Telegraph and Telephone)-Makes recommendations for international communications by listing "V" and "X" recommendations. V standards apply to telephone circuits and modems. X standards apply to public data networks. For example, CCITT recommended that X.25 be adopted as a public data network standard. (The X.25 communications protocol governs the way packets of data are transferred - V.xx modem specs, X.25 protocol.)

CCN (cash control number)-A unique code assigned to an individual financial transaction, including all refunds or repayments, before the transaction is set up within the cash-control system. The batch range within the CCN identifies the type of refund or repayment.

CCP (Change Control Process)-Reviewing, escalating, and disposing (approved or denied) any necessary changes made to project requirements.

CCP (Crippled Children's Program)-Currently known as Children's Special Health Care Services (CSHCS).

CCR (Change Control Request)-A proposed change to a project - adding, removing, or changing a requirement. The information about the proposed change is captured on the Change Control Request form.

CDDO (Community Developmental Disability Organization)-A center that manages cases and coordinates health services for beneficiaries that are mentally retarded and developmentally disabled.

CDFC (County Division of Family and Children)-Formerly CDPW, now known as the CDFR.

CDFR (County Offices of the Division of Family Resources)-County offices of FSSA servicing families and children through Temporary Assistance for Needy Families (TANF), food stamps, housing, child care, foster care, adoption, energy assistance, homeless services, and job programs. Local offices are located in each of Indiana's 92 counties. Caseworkers enroll members in the IHCP. Replaces CDFC, CDPW, OFR and OFC.

CDPW (County Department of Public Welfare)-Replaced by the County Offices of the Division of Family and Children (CDFC).

Center For Independent Living (CIL)-An agency that provides training in transitional living skills. These agencies may be accredited by a nationally recognized body, such as the Commission on Accreditation of Rehabilitation Facilities; or they may have received grants from the state or federal government and meet the standards for independent living under the Rehabilitation Act of 1973, Title VII, part B, sections A-K (or comparable standards established by the State); or they may be licensed by the State to provide independent or semi-independent living services.

Centers for Medicare & Medicaid Services (CMS)-The agency within the U.S. Department of Health and Human Services that is responsible for administering Title XIX and Title XXI of the Social Security Act. CMS oversees the Medicaid and Medicare programs and is responsible for the IHCP. It also runs the Child Health Insurance Program with the help of the Health Resources and Services Administration. CMS was formerly known as the Health Care Financing Administration (HCFA).

Central Region-An enrollment area in Central Indiana that includes the following counties: Boone, Hamilton, Hancock, Hendricks, Johnson, Madison, Marion, Morgan, Putnam, Rush, and Shelby. The enrollment area was effective for Hoosier Healthwise - RBMC January 1, 2007; for the Care Select program, November 1, 2007.

Central Region - terminated December 31, 2006-A Hoosier Healthwise enrollment area in Central Indiana that included the following counties: Benton, Blackford, Boone, Carroll, Clinton, Delaware, Fayette, Fountain, Grant, Hamilton, Hancock, Hendricks, Henry, Howard, Jay, Johnson, Madison, Marion, Montgomery, Morgan, Parke, Putnam, Randolph, Rush, Shelby, Tippecanoe, Tipton, Union, Vermillion, Warren, and Wayne.

Certificate of Medical Necessity (CMN)-Form completed by the provider attesting to the member's eligibility for services, the necessity for services provided, and the treatment's cost effectiveness. The certificate also states that the services are part of a prudent course of treatment prescribed by the provider.

certification-A CMS review of an operational MMIS in response to a state's request for 75 percent federal financial participation. This review ensures that the system meets all legal and operational requirements and also that a favorable review leads to certification.

Certification and Transmittal (C&T)-An Indiana State Department of Health (ISDH) document used to certify an institutional provider. The C&T is also used when a facility experiences changes to its existing business.

Certification by Physician for Long-Term Care Services-State Form 38143 (R5/6-93)/Form 450B/PASRR2A; generally known as form 450B. Completed by the physician to obtain medical information from the attending physician to determine medical needs for level-of-care for the following:

Admission to and Medicaid reimbursement for nursing facilities
Medicaid reimbursement for intermediate care facilities for the mentally retarded/developmentally disabled
Medicaid home- and community-based services waiver programs
State-funded Community and Home Option to Institutional Care for the Elderly and Disabled program

This form, generally known as the form 450B, may be used by other programs under the Division of Disability, Aging, and Rehabilitative Services.

certification code-A two-digit code assigned to each PMP enrolled in the Medicaid Select or Care Select network. PMPs use the certification codes to authorize specialty care, or other medical services or equipment for members assigned to their panels.

Certification Code Letter-Informs PMPs of their confidential certification codes for the current and previous quarters. Certification Code Letters are generated and mailed quarterly to the service location of each actively enrolled Medicaid Select or Care Select PMP.

certification date-An effective date specified in a written approval notice from CMS to the State when 75 percent federal financial participation (FFP) is authorized for the administrative costs of an MMIS.

certified beds-Beds in a facility that is authorized to receive government reimbursement.

CFR (Code of Federal Regulations)-Federal regulations that implement and define federal Medicaid law and regulations.

CHAMPUS (Civilian Health and Medical Plan for the Uniformed Services)-Now known as TRICARE. Healthcare plan for military active-duty family members, military retirees, and family members of military retirees who exercise the option to obtain civilian medical treatment. CHAMPUS may be considered a possible source for third-party coverage.

change control-The exercise of authority over changes to configuration items, including impact analysis, prioritizing, granting access, signing out, approving or rejecting, capturing change contents, and adding.

Change Control Board (CCB)-A group of project leaders who review (approve or deny) changes to project requirements.

Change Control Process (CCP)-Reviewing, escalating, and disposing (approved or denied) any necessary changes made to project requirements.

Change Control Request (CCR)-A proposed change to a project - adding, removing, or changing a requirement. The information about the proposed change is captured on the Change Control Request form.

Change Implementation Board (CIB)-See change request and change order information on Project Workbook.

change of ownership (CHOW)-Providers must send written notice to the Indiana Family and Social Services Administration (FSSA) or to HP of any change in direct or indirect ownership or controlling interest; corporate reorganization; change in legal or doing-business-as name; or change in federal tax identification number.

change order (CO)-The documentation of a modification to the transfer system. A change order is not a modification of a requirement; it is the modification of the base system to meet an existing requirement.

change request (CR)-The method by which changes to the MMIS for Indiana are requested. A change or modification to the operations of the OMPP, its contractors, business areas, or supporting systems.

change request number-Digits assigned to a change request for tracking purposes. Numbers are assigned in sequence.

change triggers (CR)-Areas that caused the change.

character recognition-The ability of a machine to read human-readable text.

character validation-As each character is entered into a system by the data entry operator, its validity is checked and the character is corrected, if necessary.

charge center-A provider accounting unit within an institution used to accumulate specific cost data related to medical and health services rendered (for example, laboratory tests, emergency room services, and so forth).

check (reimbursement)-Payment made to an IHCP provider, pursuant to federal and state law, as compensation for providing covered services to members.

checkwrite-All program payments issued by HP to IHCP providers. These payments can be in the form of checks or electronic funds transfers (EFTs).

Chief Security & Privacy Office (CSPO)-The HP CSPO is responsible for the development, communication, and governance of HP' enterprise security and privacy policies, strategy, and direction. Teams within the CSPO focus on privacy, policy management, information security, executive support, crisis management, business support, global operations, compliance management, and global investigations.

Child Protective Services (CPS)-The division of the Family and Social Services Administration that investigates reports of abuse and neglect of children. It also provides services to children and families in their own homes, contracts with other agencies to provide clients with specialized services, places children in foster care, provides services to help youth in foster care make the transition to adulthood, and places children in adoptive homes.

Child Support Enforcement (CSE)-Programs responsible for establishing reimbursement judgments against absent parents for Medicaid payments made on behalf of children who are Medicaid beneficiaries. CSE also establishes a legal obligation for obtaining and maintaining health insurance coverage for dependents. Health insurance coverage maintained by absent parents and other responsible parties is entered into the MMIS as third-party liability resources.

Children's Health Insurance Program (CHIP)-A part of the Balanced Budget Act of 1997 that extends the Medicaid program to children ages 0 to 19 years whose family income is at the federal poverty level (FPL). Also known as
Package C.

CHIP is a component of Indiana's Hoosier Healthwise program, which serves CHIP populations, as well as Medicaid-eligible children, low-income families, and pregnant women. Phase I of Indiana CHIP expanded the existing Medicaid program to provide health insurance to children with family incomes of not more than 150 percent of the federal poverty level. Phase II of the Children's Health Insurance Program provided health insurance coverage to children below the age of 19 with family incomes between 150 and 200 percent of the federal poverty level. CHIP II families are required to pay premiums.

Children's Special Health Care Services (CSHCS)-A State-funded program providing assistance to children with chronic health problems. CSHCS members do not have to be IHCP-eligible. If they are also eligible for the IHCP, children can be enrolled in both programs. Formerly known as Crippled Children's Program (CCP).

CHIP (Children's Health Insurance Program)-A part of the Balanced Budget Act of 1997 that extends the Medicaid program to children ages 0 to 19 years whose family income is at the federal poverty level (FPL). Also known as
Package C.

CHOICE (Community and Home Option to Institutional Care for the Elderly and Disabled)-The CHOICE program arose from The Indiana Home Care Task Force in 1986. It supports programs that provide affordable and quality home healthcare services for Indiana citizens.

CHOW (change of ownership)-Providers must send written notice to the Indiana Family and Social Services Administration (FSSA) or to HP of any change in direct or indirect ownership or controlling interest; corporate reorganization; change in legal or doing-business-as name; or change in federal tax identification number.

CIB (Change Implementation Board)-See change request and change order information on Project Workbook.

CICS (Customer Information Control System)-An IBM software that provides online user interface to MMIS data - the "front end" of the mainframe-based MMIS online system. Originally developed to provide transaction processing for IBM mainframes, CICS controls the interaction between applications and users, and lets programmers develop screen displays without detailed knowledge of the terminals used. It provides terminal routing, password security, transaction logging for error recovery, and activity journals for performance analysis. CICS commands are written along with and into the source code of the applications, typically common business-oriented language (COBOL).

CIL (Center For Independent Living)-An agency that provides training in transitional living skills. These agencies may be accredited by a nationally recognized body, such as the Commission on Accreditation of Rehabilitation Facilities; or they may have received grants from the state or federal government and meet the standards for independent living under the Rehabilitation Act of 1973, Title VII, part B, sections A-K (or comparable standards established by the State); or they may be licensed by the State to provide independent or semi-independent living services.

CIRPNCCAF (Combined Initial and Reassessment Prenatal Care Coordination Assessment Form)-Completed over time by the prenatal care coordinator to track events from conception to outcome.

Civilian Health and Medical Plan for the Uniformed Services (CHAMPUS)-Now known as TRICARE. Healthcare plan for military active-duty family members, military retirees, and family members of military retirees who exercise the option to obtain civilian medical treatment. CHAMPUS may be considered a possible source for third-party coverage.

claim-A provider's request for reimbursement of IHCP-covered services. Claims are submitted to the State's claims-processing contractor using standardized claim forms or the corresponding electronic transmissions: CMS-1500 (837P), UB-04 (837I), American Dental Association (ADA) Dental Form (837D), and State-approved pharmacy claim forms. Each claim is formatted into three levels of information: header, detail, and trailer (see below).

claim adjustment-A modification to some part of the data of a previously paid claim. All adjustments will maintain audit trails to deny adjustments to previously adjusted claims. A message is displayed stating that the claim has already been adjusted or denied. (See adjusted claim.)

claim correction form (CCF)-Generated by IndianaAIM and sent to the provider who submitted the claim. The CCF requests that the provider return the CCF with additional or corrected information within a certain time frame. These forms were discontinued as of 9/1/09

claim credit-A claim transaction that has the effect of reversing a previously processed claim transaction.

claim detail-Information specific to each service provided.

claim header-Information that relates to the beneficiary: name, Medicaid ID number, third-party coverage, diagnoses, and so forth.

claim history-All claims processed in the MMIS are kept available in the system and are referred to as being "in history."

claim note-Providers can send additional information.

claim pricing-A line item of a serialized document that identifies the services for a single beneficiary from a single provider with the same date or dates of service. The document is processed through the MMIS for payment or denial.

Exceptions are hospital inpatient claims in which an entire UB92 document is a claim. For long-term care facilities, each change in patient status within a month creates a separate long-term claim; otherwise the entire month is one long-term claim. For transportation services, a claim is counted as one item for all procedures rendered for a single beneficiary from a single provider on the same date of service. Not counted as claims are:

All voids or adjustments, or previous paid claims
Claims resulting from retroactive changes in hospital and nursing home rates
Claims transferred from one provider's history record to another
Claims which must be reprocessed as a result of a contractor's error

Electronic media claims are defined for reimbursement purposes to be identical to paper claims, regardless of ECM record definition. Each primary care case management fee paid is counted as a claim. Case management fees for capitated managed care plans are not counted as claims. This is the definition used to calculate all claim volumes given throughout the RFP, except where specifically stated otherwise.

claim processing-The paper or electronic form required for providers to bill their services. (See claim.)

claim remark code-An explanation of claim payment.

claim trailer-Information that relates to the claim charge summary: total charges, other insurance payment, and billing provider data (name, ID number, patient account number, and so forth).

claim transaction-Any of the records processed through the claims processing subsystem. Examples are claims, credits, and adjustments.

claim type -Three-digit numeric code that refers to the different billing forms used by the IHCP.

Claim types indicate the classification of claims by origin or type of service. In the Medicaid Management Information System (MMIS), this is a user-defined data element that refers to the kind of service being billed. For example, common claim types are dental, pharmacy, transportation, nursing, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), physician, inpatient, and so forth.

Outside the MMIS, the term often refers to the invoice type, such as CMS-1500, UB-04, and so forth. The invoice type could be the claim type in an MMIS, but because more than one type of service can be billed on an invoice, the term "claim type" is usually defined in more detail.

Claims Analysis and Recovery (CAR)-A unit that is responsible for reviewing claims data at the systems level to determine aberrant billing patterns. The unit also conducts payment studies based on the information found. CAR staff reviews IHCP claims reimbursement compared to existing policy and coding guidelines to identify potential overpayments. Referrals may come from other units, or they may be the result of surveillance and utilization review audits. Identified issues or referrals are then turned into CAR projects. CAR staff performs research and builds queries to support the project's focus. If, after review, CAR staff determines that a medical record is needed to verify the validity of the payment, the project will be referred to surveillance and utilization review for audit.

claims cycle-The weekly batch computer runs for Medicaid claims. There are three runs during each week - usually Monday, Tuesday, and Thursday. The final weekly run on Thursday includes a reconciliation process for the week.

claims history file-Computer files of all claims, including crossovers and all subsequent adjustments that have been adjudicated by the MMIS.

claims processing agency-Performs the claims processing function for IHCP. The agency may be a department of the single state agency responsible for Title XIX or a contractor of the agency, such as a fiscal agent.

class of service-A set of attributes that determines which functions users can perform with their telephones.

clean claim-A claim that can be processed without requiring additional information from the provider or from a third party, including claims with errors originating in the state's claim system. Clean claims do not include claims from providers under investigation for fraud or abuse, or claims under review for medical necessity. This is a federal term related to the requirement that Medicaid agencies process
90 percent of all clean claims within 30 days of receipt.

clear desk practice-A practice that ensures that no protected health information is exposed to those who do not have a "need to know" the information. This policy includes not leaving protected health information exposed on your desk, locking your computer when you leave your desk so no one else can see your display, and positioning your monitor on your desk so no one can walk up behind you and see information on the screen.

clerk ID-A code assigned to personnel involved with processing records in the MMIS claims processing system.

CLIA (Clinical Laboratory Improvement Amendments)-A process used by CMS to certify clinical and medical laboratories.

client-A person enrolled in the IHCP and thus eligible to receive services funded through the IHCP. A term primarily used to refer to a beneficiary in the Early and Periodic Screening, Diagnosis and Treatment tracking system.

client obligation-A beneficiary's monetary obligation to a provider that is determined by level of income.

Clinical Advisory Committee (CAC)-The committee established by the OMPP comprising actively participating medical providers enrolled in Hoosier Healthwise. The CAC's mission is to advise the OMPP by making recommendations that support the quality, accessibility, appropriateness, and cost-effectiveness of health and medical care provided to Hoosier Healthwise members.

clinical hierarchy-Categories of nursing facility residents, developed using residents' characteristics and required services, that classify residents by cost or staff time received. For the Resource Utilization Group (RUG-III) system, this includes groups such as Special Rehabilitation, Extensive Services, Special Care, Clinically Complex, Impaired Cognition, Behavioral Problems, and Reduced Physical Functions.

Clinical Laboratory Improvement Amendments (CLIA)-A process used by CMS to certify clinical and medical laboratories.

closed formulary-A list of drugs covered for a particular program, with use exclusively restricted to this list. The State limits drugs for which it will pay.

CM (case manager)-An experienced professional (for example, nurse, doctor, or social worker) who works with clients, providers, and insurers to coordinate all services required to provide clients with medically necessary, cost-effective, and appropriate healthcare.

CMHC (community mental health center)-A center that provides mental health treatment, including diagnostic evaluations, psychological testing, therapy (family, group, and individual), and medication checks. CMHCs are the gatekeepers of mental health services for Medicaid-eligible persons 21 years of age and under. The centers determine which services are appropriate and send Certificates of Need to providers and to the Department of Mental Health, which, in turn, forwards the information (batch tape) to the MMIS.

CMI (case-mix index)-A numeric score that identifies the relative resources used by a particular group of nursing facility residents. The CMI represents the average resource consumption across a population or sample.

CMMI (Capability Maturity Model Integration)-Models that contain the essential elements of effective processes for one or more bodies of knowledge. These models provide guidance when developing processes, though they are not processes or process descriptions; the actual processes depend on the application domain, organization structure, size, environment, and so forth.

CMN (Certificate of Medical Necessity)-Form completed by the provider attesting to the member's eligibility for services, the necessity for services provided, and the treatment's cost effectiveness. The certificate also states that the services are part of a prudent course of treatment prescribed by the provider.

CMO (care management organization)-An entity that is a primary care case manager, as defined by 42 Code of Federal Regulations (CFR) 438.2.

CMS (Centers for Medicare & Medicaid Services)-The agency within the U.S. Department of Health and Human Services that is responsible for administering Title XIX and Title XXI of the Social Security Act. CMS oversees the Medicaid and Medicare programs and is responsible for the IHCP. It also runs the Child Health Insurance Program with the help of the Health Resources and Services Administration. CMS was formerly known as the Health Care Financing Administration (HCFA).

CMS-1500-CMS-approved standardized claim form used to bill professional services. Formerly referred to as HCFA-1500. The electronic transaction equivalent is the 837 P.

CO (change order)-The documentation of a modification to the transfer system. A change order is not a modification of a requirement; it is the modification of the base system to meet an existing requirement.

COB (coordination of benefits)-When Medicaid and other primary insurance companies coordinate their benefits to ensure that beneficiaries and providers do not receive duplicate payments for services.

COBRA (Consolidated Omnibus Budget Reconciliation Act)-A law that requires employers to cover employees under the employers' group health plans for a period of time after the death of a spouse, a job loss, a reduction in work hours, or a divorce. An employee may have to pay both his or her share and the employer's share of the premium.

Code of Federal Regulations (CFR)-Federal regulations that implement and define federal Medicaid law and regulations.

cohort-A population group that shares a common property, characteristic, or event, such as the year of birth or year of marriage.

coinsurance-The amount or percentage of a covered medical cost that a patient pays after the deductible has been met. If the beneficiary is eligible for Medicaid, the coinsurance or a percentage amount will be paid by the IHCP.

Combined Initial and Reassessment Prenatal Care Coordination Assessment Form (CIRPNCCAF)-Completed over time by the prenatal care coordinator to track events from conception to outcome.

Commerce Clearing House Guide-A publication containing Medicaid and Medicare regulations.

Commission on Accreditation of Rehabilitation Facilities (CARF)-Reviews and grants accreditation at the request of facilities or programs, such as behavioral health organizations, aging services, medical rehabilitation facilities, and so on. CARF conducts on-site surveys and works with providers to help them meet its accreditation standards.

communication software-Software that adds protocols to electronic data interchange documents so the documents can be transmitted over telecommunications networks.

Community Alternatives to Psychiatric Residential Treatment Facilities (CA-PRTF)-A program for IHCP members who qualify for treatment at a psychiatric residential treatment facility at a level of care that allows the member to receive services in the community.

Community and Home Option to Institutional Care for the Elderly and Disabled (CHOICE)-The CHOICE program arose from The Indiana Home Care Task Force in 1986. It supports programs that provide affordable and quality home healthcare services for Indiana citizens.

Community Developmental Disability Organization (CDDO)-A center that manages cases and coordinates health services for beneficiaries that are mentally retarded and developmentally disabled.

community mental health center (CMHC)-A center that provides mental health treatment, including diagnostic evaluations, psychological testing, therapy (family, group, and individual), and medication checks. CMHCs are the gatekeepers of mental health services for Medicaid-eligible persons 21 years of age and under. The centers determine which services are appropriate and send Certificates of Need to providers and to the Department of Mental Health, which, in turn, forwards the information (batch tape) to the MMIS.

community-based screening-An assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals to determine their eligibility for long-term care.

compendium-Collection of drug information. Under the Federal Food, Drug, and Cosmetic Act, standards for strength, quality, and purity of drugs are set forth in one of three official compendia: The United States Pharmacopoeia, the Homeopathic Pharmacopoeia of the United States, and the National Formulary (or any of their respective supplements).

Complaint/grievance-A verbal or written expression of concern about a situation that can be resolved informally.

Grievance=formal
Complaints=informal.

confirmation number-Number given to the person calling for nonemergency medical transportation. This number helps track and identify the request.

Consolidated Omnibus Budget Reconciliation Act (COBRA)-A law that requires employers to cover employees under the employers' group health plans for a period of time after the death of a spouse, a job loss, a reduction in work hours, or a divorce. An employee may have to pay both his or her share and the employer's share of the premium.

consultation time-The time an agent spends on two or more lines at once - for example, while a call is on hold or during a conference call.

Consultative Committee on International Telegraph and Telephone (CCITT)-Makes recommendations for international communications by listing "V" and "X" recommendations. V standards apply to telephone circuits and modems. X standards apply to public data networks. For example, CCITT recommended that X.25 be adopted as a public data network standard. (The X.25 communications protocol governs the way packets of data are transferred - V.xx modem specs, X.25 protocol.)

consumer explanation of benefits letter-Form letters generated by the fiscal agent and distributed to consumers detailing services provided to members by the IHCP.

Consumer Price Index (CPI)-An economic figure prepared by the Department of Labor's Bureau of Labor Statistics that tracks changes in the average prices of goods and services in different sectors of the economy. The medical care component gives trends in medical care charges based on specific indicators of hospital, medical, dental, and drug prices.

Contact Tracking Management System (CTMS)-This ancillary application provides access and storage for information associated with customer service contacts. All contact information is associated with a contact tracking number (CTN). This information includes contact type, demographic information, questions, resolutions, and contact reasons. HP and FSSA staff enter information for each contact through online windows. Search windows allow users to sort and access contacts based on a variety of criteria. Reports are available based on open dates, status, clerk IDs and department.

contact tracking number (CTN)-A system-generated tracking number assigned to any request that is opened in CTMS.

contract amendment-Any written change in the specifications, delivery point, rate of delivery, contract period, price, quantity, or other provisions of an existing contract. These changes may be initiated by one or both parties to the contract. Amendments may also include bilateral actions, such as change orders, administrative changes, notices of termination, and notices of the exercise of a contract option.

contract start date-The date an agreement for services in an RFP becomes effective.

contracting-Indicates that a provider has signed a legal managed-care agreement with the State.

contractor, contractors, or the contractor-Successful bidders responding to RFPs or invitations to bid. A person or organization from which the State contracts for products or service.

Auditing contractor - The entity that conducts audits of long-term care facilities, or other functions and activities, as designated by the OMPP.

Fiscal agent contractor - The entity that performs claims processing and provider-payment activities for the State.

Rate-setting contractors - Entities under contract with the OMPP to set rates for Medicaid-approved institutional and residential facilities.

controlled drugs / scheduled drugs-Drugs classified as narcotics, sedative, hypnotics, and stimulants, that have high potential for abuse. There are five schedules, with Schedule I drugs being the most dangerous.

conversion factor-The factor used to convert units of service; applicable to drug claims being processed in drug rebate.

coordination of benefits (COB)-When Medicaid and other primary insurance companies coordinate their benefits to ensure that beneficiaries and providers do not receive duplicate payments for services.

copay/copayment-A charge the beneficiary is responsible for paying for selected procedures or services. It is the patient's responsibility to pay some fixed portion of the cost of medical service, while the insurer pays the remainder.

core contractor-The successful bidder on Service Package #1: Claims Processing and Related Services.

core services-Refers to Service Package #1: Claims Processing and Related Services.

Corrective Action Plan (CAP) [Ancillary Application]-An application that provides access and storage for all information associated with all CAPs, enabling HP and the FSSA staff to efficiently manage the CAP process. This plan is initiated by the FSSA contract monitor and submitted to the fiscal agent whenever areas of noncompliance have not been satisfactorily resolved through the preceding CAP.

COS (category of service)-The type of service a provider renders (for example, inpatient hospital, outpatient hospital, transportation, prescribed drugs, pharmacy, hospice, physician care, family planning services, therapy, crossover, and so forth).

The category under which the financial transaction should be reported.

cost avoidance-A Medicaid claim may be denied when other insurance coverage exists and there is no indication that the other carrier has been billed (cost avoided).

cost sharing-Provisions of an insurance policy requiring the covered individual to pay some portion of covered medical expenses. Premium amounts are not included in cost sharing. Deductibles (set amounts paid before payment of benefits occurs), copayments (fixed amounts paid for each service), and coinsurance (payment of a set portion of the cost per service) are forms of cost sharing.

counters-The mechanism that keeps track of the number of times the telephone system encounters an error or an agent reports an interference problem. Counters can also track queue time, ring time, talk time, and so forth.

County Department of Public Welfare (CDPW)-Replaced by the County Offices of the Division of Family and Children (CDFC).

County Office-County offices of the Division of Family and Children. Offices responsible for determining eligibility for Medicaid and IHCP using the Indiana Client Eligibility System (ICES). A link to their addresses can be found under the link section of this site.

County Offices of the Division of Family Resources (CDFR)-County offices of FSSA servicing families and children through Temporary Assistance for Needy Families (TANF), food stamps, housing, child care, foster care, adoption, energy assistance, homeless services, and job programs. Local offices are located in each of Indiana's 92 counties. Caseworkers enroll members in the IHCP. Replaces CDFC, CDPW, OFR and OFC.

coverage code-A system of letters or numbers assigned to the type of coverage provided by a third-party carrier's policy.

covered service-Mandatory medical services required by CMS and optional medical services approved by the State. Enrolled providers are reimbursed for these services provided to eligible Medicaid recipients.

CPI (Care Plan Index)-A weighted value assigned to beneficiaries residing in nursing facilities based on care required. The index is used to determine a provider's case mix.

CPI (Consumer Price Index)-An economic figure prepared by the Department of Labor's Bureau of Labor Statistics that tracks changes in the average prices of goods and services in different sectors of the economy. The medical care component gives trends in medical care charges based on specific indicators of hospital, medical, dental, and drug prices.

CPS (Child Protective Services)-The division of the Family and Social Services Administration that investigates reports of abuse and neglect of children. It also provides services to children and families in their own homes, contracts with other agencies to provide clients with specialized services, places children in foster care, provides services to help youth in foster care make the transition to adulthood, and places children in adoptive homes.

CPT^® (Current Procedural Terminology)-Part of the standard code set selected by HIPAA to describe healthcare services in electronic transactions. CPT was developed by the American Medical Association in the 1960s and became part of the standard code set for Medicare and Medicaid. It has since been adopted by private insurance carriers and managed care companies, and has become the de facto standard.

CPT-4 (Current Procedural Terminology, Fourth Edition)-A book published by the American Medical Association that contains CPT codes used by medical practitioners when billing for Medicaid. The CPT codes are also included as Level One codes in the Healthcare Common Procedure Coding System.

CR (change request)-The method by which changes to the MMIS for Indiana are requested. A change or modification to the operations of the OMPP, its contractors, business areas, or supporting systems.

credit-A financial transaction that reverses a previously paid claim to zero; a credit is entered in the MMIS just like a claim. Providers can request credits if they have been paid for services they did not perform. The State agency can also request credits. Also known as credit-only adjustment.

Crippled Children's Program (CCP)-Currently known as Children's Special Health Care Services (CSHCS).

critical access hospital (CAH)-A freestanding hospital emergency department providing limited inpatient care, as needed, to stabilize patients before discharge or transfer to an essential access community hospital for extensive treatment.

cross walk-To convert one code to another. Written as two words when used as a verb.

crossover claim-If a beneficiary is eligible for both Medicare and Medicaid, the Medicare claim is automatically sent to Medicaid after the Medicare carrier processes it. The claim, in effect, crosses over from one system to the other via tapes or disks. There are also paper crossover claims, which are submitted by providers who do not accept assignment or who were denied payment by Medicare. It is important to know that Medicaid is considered the payer of last resort. Therefore, claims must always be sent to Medicare first when a beneficiary is eligible for both programs.

crosswalk-A table used to convert one code to another code; or the act of converting one code to another. Also known as data mapping. Written as one word when used as a noun or adjective.

CSE (Child Support Enforcement)-Programs responsible for establishing reimbursement judgments against absent parents for Medicaid payments made on behalf of children who are Medicaid beneficiaries. CSE also establishes a legal obligation for obtaining and maintaining health insurance coverage for dependents. Health insurance coverage maintained by absent parents and other responsible parties is entered into the MMIS as third-party liability resources.

CSHCS (Children's Special Health Care Services)-A State-funded program providing assistance to children with chronic health problems. CSHCS recipients do not have to be Medicaid-eligible. If they are also eligible for Medicaid, children can be enrolled in both programs. Formerly known as Crippled Children's Program (CCP).

CSPO (Chief Security & Privacy Officer)-The HP CSPO is responsible for the development, communication, and governance of HP' enterprise security and privacy policies, strategy, and direction. Teams within the CSPO focus on privacy, policy management, information security, executive support, crisis management, business support, global operations, compliance management, and global investigations.

CTMS (Contact Tracking Management System)-This ancillary application provides access and storage for information associated with customer service contacts. All contact information is associated with a contact tracking number (CTN). This information includes contact type, demographic information, questions, resolutions, and contact reasons. HP and FSSA staff enter information for each contact through online windows. Search windows allow users to sort and access contacts based on a variety of criteria. Reports are available based on open dates, status, clerk IDs and department.

CTN (contact tracking number)-A system-generated tracking number assigned to any request that is opened in CTMS.

Current Procedural Terminology (CPT^®)-Part of the standard code set selected by HIPAA to describe healthcare services in electronic transactions. CPT was developed by the American Medical Association in the 1960s and became part of the standard code set for Medicare and Medicaid. It has since been adopted by private insurance carriers and managed care companies, and has become the de facto standard.

Current Procedural Terminology, Fourth Edition (CPT-4)-A book published by the American Medical Association that contains CPT codes used by medical practitioners when billing for Medicaid. The CPT codes are also included as Level One codes in the Healthcare Common Procedure Coding System.

customary charge-A dollar amount that represents the median charge for a given service by an individual physician or supplier.

customer-Individuals or entities that receive services or interact with the contractor supporting the Medicaid program, including State staff, recipients, and Medicaid providers - managed care PMPs, managed care organizations, and waiver providers.

Customer Information Control System (CICS)-An IBM software that provides online user interface to MMIS data - the "front end" of the mainframe-based MMIS online system. Originally developed to provide transaction processing for IBM mainframes, CICS controls the interaction between applications and users, and lets programmers develop screen displays without detailed knowledge of the terminals used. It provides terminal routing, password security, transaction logging for error recovery, and activity journals for performance analysis. CICS commands are written along with and into the source code of the applications, typically common business-oriented language (COBOL).

cutback-A reduction in quantity or rate.

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D&E (diagnostic and evaluation)-A multidisciplinary team that uses various sources of information and face-to-face meetings to screen for mental retardation and developmental disabilities (MR/DD). D&E teams must be contracted and approved by the DDRS or the BDDS to conduct PASRR Level II MR/DD assessments. Teams must also be enrolled with the IHCP to be eligible to submit Level II MR/DD claims. Providers may obtain a list of authorized D&E teams from the DDRS.

DASS (depression, anxiety, and tension/stress scales)-A 42-item self-report instrument designed to measure the three related negative emotional states of depression, anxiety, and tension/stress.

data entry-Entering information into the computer, including keyboarding, scanning, and voice recognition. When transactions are entered after the fact (batch data entry), they are just stacks of source documents to the keyboard operator. Because deciphering poor handwriting from a source document is often error-prone, online data entry, in which the operator takes information in person or by phone, entails less chance for error.

Data Interchange Standards Association-The trade organization that acts as secretariat for the American National Standards Institute (ANSI) ASC-X12 and the Pan American Electronic Data Interchange for Administration, Commerce, and Transport (EDIFACT) Board in the United States.

Data Processing Oversight Commission (DPOC)-Indiana state agency that oversees agency compliance with all State data processing statutes, policies, and procedures.

database table-A collection of similar records grouped within the telephone system. CallCenter software uses database tables to store all types of user-entered information. For example, the User table contains one record for each user in the system; the Agent Group table defines each agent group and sets options for each. All tables in the system database are accessed through the Database command on the CallCenter main menu.

date of service (DOS)-The date when a beneficiary received medical treatment, a service or product.

DB (database)-Information organized and structured in a disciplined fashion for the quickest possible access. Database management programs form the foundation for most document storage indexing systems.

DBA (doing business as)-Refers to a type of provider name and address.

DCN (document control number)-A unique digit assigned to documents submitted with claims

DDARS (Division of Disability, Aging, and Rehabilitative Services)-Serves older adults and individuals with disabilities and their families. These people need human services, resources, or support to attain employment and self-sufficiency or to maintain independence. See IDDARS.

database (DB)-Information organized and structured in a disciplined fashion for the quickest possible access. Database management programs form the foundation for most document storage indexing systems.

DDE (direct data entry)-Information transmitted immediately into a health plan's computer.

diagnosis (DX)-The classification of a disease or condition. (1) The art of distinguishing one disease from another. (2) Determining the nature of a cause of a disease. (3) A concise technical description of the cause, nature, or manifestations of a condition, situation, or problem. (4) A code for the above.

DDRS (Division of Disability and Rehabilitative Services)-Assists Indiana citizens, regardless of the severity of their disabilities, to become employed and to live in the least restrictive and most appropriate environment possible.

DDS (Disability Determination Services)-.A division of the FSSA that contracts with the Social Security Administration to determine the disability status of Social Security disability applicants.

DEA (Drug Enforcement Agency)-A federal government organization that controls the prescribing and dispensing of controlled drugs.

debit-A net change or adjustment to a previously paid claim.

Decision Support System (DSS)-A data-extraction tool used to evaluate Medicaid data, trends, and so forth, for the purpose of making program decisions.

Deductible-The out-of-pocket expense a beneficiary must pay before a third party will pay for covered medical expenses. The deductible is usually based on a calendar year.

DEERS (Defense Enrollment and Eligibility Reporting System)-Contains eligibility information on CHAMPUS, the insurance company for military dependents. CHAMPUS was replaced by TRICARE.

Default-An automated process used to make random managed-care assignments for beneficiaries who do not select primary medical providers of their own accord, or who were not assigned through auto-assignment.

Defense Enrollment and Eligibility Reporting System (DEERS)-Contains eligibility information on CHAMPUS, the insurance company for military dependents.

CHAMPUS was replaced by TRICARE.

denied (CR)-A change request that has been reviewed and denied by the OMPP Operational Effectiveness Team; or one that a director must know about. It may also be that an executive decision has been made not to move forward with the request.

denied claim-Request for payment for medical services that's not paid by the IHCP. This includes services provided to ineligible beneficiaries, services provided by an ineligible provider, or services not billed in the correct manner.

denied encounter data table-A record of all encounter data that has been denied by IndianaAIM. These tables do not include claims that failed precycle editing. Information on a denied claim is not subject to service limitation auditing and is not included in data used for utilization review.

deny-To decline to pay a claim. See denied claim.

Department of Health and Human Services (DHHS)-Also known as DHS and HHS. See U.S. Department of Health and Human Services.

Department of Human Services (DHS)-Also known as DHHS and HHS. See U.S. Department of Health and Human Services.

Department of Public Welfare (DPW)-See FSSA.

depression, anxiety, and tension/stress scales (DASS)-A 42-item self-report instrument designed to measure the three related negative emotional states of depression, anxiety, and tension/stress.

DESI (Drug Efficacy Study Implementation)-Drugs that lack substantial evidence of effectiveness and are marked as less-than-effective by the FDA. Such drugs are subject by the FDA to a Notice of Opportunity for Hearing. The CMS DESI Code (CMS_DESI) indicates the DESI code as supplied on the CMS quarterly tape.

This includes drugs that are identical, related, or similar to DESI drugs. DESI codes have values of three through six; drugs listed with DESI codes of two, three, or four are rebatable, while those with values of five or six are not. Valid values are:

0 - NDC not on CMS tape - no information submitted by manufacturer
2 - Safe and effective, or non-DESI3 - DESI/IRS Drugs Under Review (no Notice of Opportunity for a Hearing [NOOH] issued)
4 - Less-than-effective DESI/IRS Drugs for Some Indications
5 - Less-than-effective DESI/IRS Drugs for All Indications
6 - Less-than-effective DESI/IRS Drugs Removed from the Market

A DESI drug is not covered by the Indiana Health Coverage Programs (IHCP).

Federal law prohibits state Medicaid agencies from reimbursing for so-called less than effective (LTE) drugs, commonly called DESI drugs, or any drug that the federal government has determined to be identical, related, or similar (IRS) to such a drug. A comprehensive listing of these drugs can be found at www.indianamedicaid.com/ihcp/PharmacyServices/list.asp under DESI Drug List. They are listed on the Web site by name, manufacturer, dosage form, and NDC. These drugs are not covered by the IHCP and providers are not entitled to reimbursement for them.

designee-An authorized representative of a person holding a superior position.

detail-Information on a claim that denotes a specific procedure or category of services, and the total charge billed for the procedures. Also used to describe lines within a screen segment; for example, those listed to describe periods of eligibility. Also called a line item or detail line.

detail line-Information on a claim that denotes a specific procedure or category of services, and the total charge billed for the procedures. Also used to describe lines within a screen segment; for example, those listed to describe periods of eligibility. Also called a line item or detail line.

Detailed Implementation Schedule (DIS)-Before designing a new system or enhancing an existing one, CMS must approve a DIS from the State, if the new system or enhancement would be developed by State and contractor staff. The DIS must include a provision for identifying costs allocated to the design or enhancement. The State also uses the DIS to monitor and manage the design of the MMIS.

detailed system design (DSD)-Document created by the fiscal agent to use as a resource when developing new systems or subsystems.

developmental disability (DD)-Mental retardation or a related condition; a severe, chronic disability that results in impaired intellectual functioning or deficiencies in essential skills.

DFC Form 8-Formerly DPW Form 8A or State Form 11971 - Notice to Provider of Member Deductible. Used to relay recipient spend-down information to providers.

DFR (Division of Family Resources)-The state agency that offers help with job training, public assistance, food stamps, and other services. See CDFR.

DHHS (Department of Health and Human Services)-Also known as DHS and HHS. See U.S. Department of Health and Human Services.

DHS (Department of Human Services)-Also known as DHHS and HHS. See U.S. Department of Health and Human Services.

diagnosis code-The medical classification of a disease or condition according to ICD-9-CM or HCPCS;a numeric code that identifies the patient's condition, as determined by the provider of the performed service.

diagnosis-related group (DRG)-The basis for one type of hospital reimbursement. A hospital-specific fee is calculated for each diagnosis group for each hospital. Each patient's age, sex, and length of stay, as well as the historical costs for each hospital, are taken into consideration in calculating the reimbursement. Usually, mental institutions and pediatric hospitals are excluded from DRG reimbursement because those patients tend to stay longer.

diagnostic and evaluation (D&E)-A multidisciplinary team that uses various sources of information and face-to-face meetings to screen for mental retardation and developmental disabilities (MR/DD). D&E teams must be contracted and approved by the DDRS or the BDDS to conduct PASRR Level II MR/DD assessments. Teams must also be enrolled with the IHCP to be eligible to submit Level II MR/DD claims. Providers may obtain a list of authorized D&E teams from the DDRS.

Diagnostic and Statistical Manual of Mental Disorders (DSM)-Compendium of definitions of mental disorders and the associated coding system for mental diagnoses. Published by the American Psychiatric Association. A revision series number is usually associated with the acronym.

digit-Any symbol that expresses an idea or information, such as a letter, number, or punctuation.

direct data entry (DDE)-Information transmitted immediately into a health plan's computer.

direct price-What the pharmacist pays for drugs purchased from drug manufacturers.

direct-care component-One of the four case-mix components used to calculate rates. It includes all allowable nursing and nursing aide services; nurse consulting services; pharmacy consultants; medical director services; nurse aide training; medical supplies; oxygen; therapy services; and medical records costs. The other three components are: administrative, capital, and indirect-care.

DIS (Detailed Implementation Schedule)-Before designing a new system or enhancing an existing one, CMS must approve a DIS from the State, if the new system or enhancement would be developed by State and contractor staff. The DIS must include a provision for identifying costs allocated to the design or enhancement. The State also uses the DIS to monitor and manage the design of the MMIS.

Disability-A physical or mental condition that makes an insured incapable of performing one or more duties of his or any occupation.

disability benefit-A payment that arises because of the total or permanent disability of an insured; a provision added to a policy that provides for a waiver of premium in case of total and permanent disability.

Disability Determination Services (DDS)-A division of the FSSA that contracts with the Social Security Administration to determine the disability status of Social Security disability applicants.

disability income insurance-A form of health insurance that provides periodic payments when the insured is unable to work as a result of illness, disease, or injury.

disallow-To determine that billed services are not covered by the IHCP and will not be reimbursed.

disallowance projects-HMS conducts disallowance projects where it looks for claims that should have been paid by Medicare or the Federal Employee Program (FEP) and notifies the provider to submit the claim to Medicare or FEP. Once the claim is paid by Medicare or FEP, the Medicaid claim is adjusted to show this payment and the funds recouped by Medicaid.

disaster-Any situation or condition considered threatening to HP personnel, or to HP or client information or assets; or that impairs the ability of HP to deliver products or services to the client.

Disaster Recovery Plan (DRP)-The documented process designed to restore HP' essential technical and business services immediately following a disaster. The services are intended to provide minimal functions while further efforts are in progress to restore all functions to normal levels. Includes facilities, plans, tests, and so forth, to recover the MMIS from total loss.

disenrollment-Removal of assignment or from the managed-care program.

dispensing fee-A reimbursement charge added to the cost of a drug. This cost may be direct, average wholesale price, maximum allowable cost, and so forth.

disposition-Applying a cash refund to a previously finalized claim. Also used in processing claims to identify claim finalization - payment or denial.

The actual status of a claim. A processed claim is assigned a status or disposition determined by the Exception Control File.

disproportionate-share hospital (DSH)-Hospitals that serve more than their proportionate share of indigent patients, Medicaid beneficiaries, and other low-income persons.

Division of Disability and Rehabilitative Services (DDRS)-Assists Indiana citizens, regardless of the severity of their disabilities, to become employed and to live in the least restrictive and most appropriate environment possible.

Division of Disability, Aging, and Rehabilitative Services (DDARS)-Serves older adults and individuals with disabilities and their families. These people need human services, resources, or support to attain employment and self-sufficiency or to maintain independence. See IDDARS.

Division of Family Resources (DFR)-The state agency that offers help with job training, public assistance, food stamps, and other services. See CDFR.

Division of Mental Health (DMH)or Division of Mental Health and Addiction (DMHA)-The DMHA assists people with mental illness or addiction who are uninsured or underinsured, enabling these people to receive treatment and re-integrate into the community. The division operates six state hospitals and partners with Indiana's community mental health centers to provide treatment.

DME (durable medical equipment)-Nondisposable, medically necessary devices that can withstand repeated use, such as wheelchairs, hospital beds, crutches, walkers, and so on.

DME (Durable Medical Equipment) Enumeration and NPI-Assigning standard unique identifiers to Medicare DME suppliers. DME suppliers covered under the HIPAA are required to obtain national provider identifiers (NPIs) for every location. The only exception is when a Medicare DME supplier is a sole proprietor. Sole proprietors are eligible for only one NPI (the individual's NPI), regardless of the number of locations.

DME MAC (durable medical equipment Medicare administrative contractor)-Replaces DMERC beginning in 2005. For more information, see Durable Medical Equipment Medicare Administrative Contractor.

DMERC (durable medical equipment regional carrier)-DME MACs replaced DMERCs beginning in 2005. See Durable Medical Equipment Medicare Administrative Contractor.

DMH (Division of Mental Health) or DMHA (Division of Mental Health and Addiction)-The DMHA assists people with mental illness or addiction who are uninsured or underinsured, enabling these people to receive treatment and re-integrate into the community. The division operates six state hospitals and partners with Indiana's community mental health centers to provide treatment.

DMHA (Division of Mental Health and Addiction) or DMH (Division of Mental Health)-The DMHA assists people with mental illness or addiction who are uninsured or underinsured, enabling these people to receive treatment and re-integrate into the community. The division operates six state hospitals and partners with Indiana's community mental health centers to provide treatment.

DMS (document management system)-An application used to organize and control documents. The DMS includes software and supporting Publications Unit processes. The Indiana Title XIX account uses Hummingbird^®.

Document-Structured file sent to a trading partner. In ASC X12 usage, a document is synonymous with a transaction set.

document control number (DCN)-DCN. A unique digit assigned to documents submitted with claims.

document image-A computerized representation of a picture or graphic.

document management system (DMS)-An application used to organize and control documents. The DMS includes software and supporting Publications Unit processes. The Indiana Title XIX account uses Hummingbird^®.

document retrieval-The ability to search for, select, and display a document or its facsimile from storage.

doing business as (DBA)-Refers to a type of provider name and address.

DOS (date of service)-The date when a beneficiary received medical treatment, a service or product.

Dosage Range Check Module-A First DataBank (FDB) term referring to modules and alerts used to perform the Duration of Therapy alert in the Prospective Drug Utilization Review (ProDUR) system.

down-Term used to describe the inactivity of a computer because of power shortages or equipment problems. Entries on a terminal are not accepted during downtime.

DPOC (Data Processing Oversight Commission)-Indiana state agency that oversees agency compliance with all State data processing statutes, policies, and procedures.

DPW (Department of Public Welfare)-See FSSA.

DPW Form 8A-Now DFC Form 8 (State Form 11971) - Notice to Provider of Member Deductible.

DRG (diagnosis-related group)-The basis for one type of hospital reimbursement. A hospital-specific fee is calculated for each diagnosis group for each hospital. Each patient's age, sex, and length of stay, as well as the historical costs for each hospital, are taken into consideration in calculating the reimbursement. Usually, mental institutions and pediatric hospitals are excluded from DRG reimbursement because those patients tend to stay longer.

drill down-A system capability that allows users to obtain more detailed or in-depth information from queries and subsequent reports. Applies additional criteria to an existing subset of data displayed on the decision support system.

DRP (Disaster Recovery Plan)-The documented process designed to restore HP' essential technical and business services immediately following a disaster. The services are intended to provide minimal functions while further efforts are in progress to restore all functions to normal levels. Includes facilities, plans, tests, and so forth, to recover the MMIS from total loss.

DRS (Drug Rebate System)-If a drug manufacturer has a formal agreement with the CMS, and if the manufacturer's drug products are covered by Medicaid, federal regulations allow the manufacturer to give financial rebates to Medicaid, based on the volume of products dispensed.

drug-Any substance or its components recognized in one of the official drug compendia for use in the diagnosis, cure, mitigation, treatment, or prevention of disease; or one that is intended to affect the structure or function of the body.

drug class-Classifies a drug by its availability to the consumer according to federal specifications. Valid values are:

O - Over-the-counter. Containing all the proper labeling for over-the-counter sale and not requiring a prescription, as determined by the FDA.
F - Prescription required. All products designated by the FDA as requiring a prescription for dispensing.

drug code-Identifies a drug covered by the IHCP.

Drug Efficacy Study Implementation (DESI)-Drugs that lack substantial evidence of effectiveness and are marked as less-than-effective by the FDA. Such drugs are subject by the FDA to a Notice of Opportunity for Hearing. The CMS DESI Code (CMS_DESI) indicates the DESI code as supplied on the CMS quarterly tape.

0 - NDC not on CMS tape - no information submitted by manufacturer
2 - Safe and effective, or non-DESI
3 - DESI/IRS Drugs Under Review (no Notice of Opportunity for a Hearing [NOOH] issued)
4 - Less-than-effective DESI/IRS Drugs for Some Indications
5 - Less-than-effective DESI/IRS Drugs for All Indications
6 - Less-than-effective DESI/IRS Drugs Removed from the Market

A DESI drug is not covered by the Indiana Health Coverage Programs (IHCP).

Drug Enforcement Administration Code-Denotes the degree of potential abuse and federal control of a drug. This code is subject to change by federal regulation. The current code list is:

0 - No control
1 - LSD, heroin, marijuana - research only
2 - Morphine, meperidine, amphetamines, and so forth; most abused
3 - Aspirin/codeine, and so forth; less abused
4 - Valium, and so forth; potential abuse
5 - Controlled sale by pharmacy only

Drug Enforcement Agency (DEA)-A federal government organization that controls the prescribing and dispensing of controlled drugs.

drug formulary-List of drugs covered by a state Medicaid program, which includes the drug's code, description, strength, and manufacturer.

Drug Labeler Rebate Status-The drug rebate status shows whether a labeler (NDC 5) is participating in the CMS rebate program. The labeler's rebate status is received from First DataBank (FDB) weekly. The update process uses the FFPRM_I and the FFPRM_C to maintain the labeler's status in the rebate program. Valid FFPRM_I values are:

0 - Nonparticipating rebate manufacturer
1 - Participating rebate manufacturer

Drug Rebate System (DRS)-If a drug manufacturer has a formal agreement with the CMS, and if the manufacturer's drug products are covered by Medicaid, federal regulations allow the manufacturer to give financial rebates to Medicaid, based on the volume of products dispensed.

Drug Utilization Review (DUR)-Using drug databases to measure and assess the use of prescription drugs. DUR helps dispensers ensure patients' safety, examine dosing options, and check drug-to-drug interactions. It includes both prospective reviews - that is, checking patients' prescriptions before they're dispensed - and retrospective reviews (looking over drug data after prescriptions are dispensed to find overall patterns and monitor how the drugs are prescribed and used on a larger scale). For example, drug use is reviewed by cost, by provider, and so on. DUR is federally mandated for Medicaid.

drug wholesaler-Source from which pharmacists can buy drug supplies.

drug-to-drug interactions-Edits built into the pharmacy point-of-sale system to prevent dispensing potentially dangerous combinations of drugs.

DSD (detailed system design)-Document created by the fiscal agent to use as a resource when developing new systems or subsystems.

DSH (disproportionate share hospital)-Hospitals that serve more than their proportionate share of indigent patients, Medicaid beneficiaries, and other low-income persons.

DSM (Diagnostic and Statistical Manual of Mental Disorders)-Compendium of definitions of mental disorders and the associated coding system for mental diagnoses. Published by the American Psychiatric Association. A revision series number is usually associated with the acronym.

DSS (Decision Support System)-A data-extraction tool used to evaluate Medicaid data, trends, and so forth, for the purpose of making program decisions.

dual eligible-A person enrolled in Medicare and Medicaid.

dually certified beds-Beds in a facility that are certified for Medicare (Title XIIX) and Medicaid (Title XIX) reimbursement.

duplicate claim-A claim for totally or partially identical services that has been previously paid.

duplicate payment-Reimbursing a provider more than once for the same services.

DUR (Drug Utilization Review)-Using drug databases to measure and assess the use of prescription drugs. DUR helps dispensers ensure patients' safety, examine dosing options, and check drug-to-drug interactions. It includes both prospective reviews - that is, checking patients' prescriptions before they're dispensed - and retrospective reviews (looking over drug data after prescriptions are dispensed to find overall patterns and monitor how the drugs are prescribed and used on a larger scale). For example, drug use is reviewed by cost, by provider, and so on. DUR is federally mandated for Medicaid.

durable medical equipment (DME)-Nondisposable, medically necessary devices that can withstand repeated use, such as wheelchairs, hospital beds, crutches, walkers, and so on.

Durable Medical Equipment (DME) Enumeration and NPI-Assigning standard unique identifiers to Medicare DME suppliers. DME suppliers covered under the HIPAA are required to obtain national provider identifiers (NPIs) for every location. The only exception is when a Medicare DME supplier is a sole proprietor. Sole proprietors are eligible for only one NPI (the individual's NPI), regardless of the number of locations.

durable medical equipment Medicare administrative contractor (DME MAC)-Replaces DMERC beginning in 2005. For more information on the CMS Web site under Durable Medical Equipment Medicare Administrative Contractor.

durable medical equipment regional carrier (DMERC)-DME MACs replaced DMERCs beginning in 2005. See Durable Medical Equipment Medicare Administrative Contractor.

DX (diagnosis)-The classification of a disease or condition. (1) The art of distinguishing one disease from another. (2) Determining the nature of a cause of a disease. (3) A concise technical description of the cause, nature, or manifestations of a condition, situation, or problem. (4) A code for the above.

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E1-A type of eligibility query performed by pharmacists and prescription providers to verify Medicare Part D coverage.

EAC (estimated acquisition cost of drugs)-A federal pricing requirement for drugs; an approximation of the cost at which most providers can buy drugs in the most frequently purchased package size.

Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT)-A program for Medicaid-eligible recipients under the age of 21 that offers free preventive healthcare services, such as screenings, well-child visits, and immunizations. If medical problems are discovered, the recipient is referred for further treatment. The program's goal is early detection and prevention of conditions that can result in more costly treatment or long-term effects. Also known as HealthWatch.

Early Intervention Program (EIP), Early Intervention System (EIS)-Programs that provide financial assistance to eligible individuals and families so they have easy access to comprehensive and preventive medical coverage. Examples are the AIDS Drug Assistance Program and First Steps.

East Central Region-An enrollment area in East Central Indiana that includes the following counties: Blackford, Cass, Delaware, Fayette, Grant, Henry, Howard, Jay, Randolph, Tipton, Union, and Wayne. The enrollment area for Hoosier Healthwise -RBMC was effective January 1, 2007, and for Medicaid Care Select March 1, 2008.

EBT (electronic benefits transfer)-Allows the State to issue food stamps and benefit checks electronically by using plastic Beneficiary ID Cards. Conforms to ANSI Uniform Health Care ID Card Standards.

ECC (electronic claims capture)-The direct transmission of electronic claims over telephone lines to IndianaAIM. ECC uses point-of-sale devices and PCs to verify eligibility, capture claims, apply ProDUR, edit prepayments, and respond to and accept claims submitted online. Also known as electronic claims submission and electronic media claims.

ECF (extended care facility)-An inpatient institution for the care of patients in nonacute conditions. Most commonly, a long-term care, nursing home, or nursing facility.

ECM (electronic claims management)-A system that captures claims over telephone lines facilitated by networks, and adjudicates claims submitted by providers online in real time. Paperless claims.

ECS (electronic claims submission)-Claim transmittal via electronic media.

EDI (electronic data interchange)-Standard format for exchanging business data. This usually means X12 and similar variable-length formats for the electronic exchange of data between different companies using networks, such as the Internet. It is sometimes used more broadly to mean any electronic exchange of formatted data.

edit-A set of parameters in the MMIS against which claim transactions are "edited." An example is the eligibility edit, which enforces the restriction that a member must be actively enrolled in the Medicaid program before the program will pay for services. These edits can detect errors, stop payments, and generate reports.

HP-,The Indiana medical assistance programs' fiscal agent..

EFI (electronic file interchange)-Batch-mode enumeration (assigning standard unique identifiers) of multiple providers by a third party. (NPI Final Rule, Page 3448, Federal Register /Vol.69 No.15 / defines bulk enumeration as "mass enumeration of a large number of healthcare providers, all at one time, from a database or file that uniquely identifies them in a way consistent with the identification criteria in this final rule.")

EFIO (electronic file interchange organization)-An organization certified by CMS to submit NPI applications via EFI on behalf of, and with the authorization of, a group of providers.

EFNEP (Expanded Food and Nutrition Education Program)-Designed to help audiences with limited resources acquire the knowledge, skills, attitudes, and changed behavior necessary to follow nutritionally sound diets.

EFT (electronic fund transfer) warrants-See warrant.

EFT (electronic funds transfer)-Paying providers for approved claims via electronic transfer of funds from the State directly to providers' accounts.

EIP (Early Intervention Program), EIS (Early Intervention System)-Programs that provide financial assistance to eligible individuals and families so they have easy access to comprehensive and preventive medical coverage. Examples are the AIDS Drug Assistance Program and First Steps.

EIS (Early Intervention System), EIP (Early Intervention Program)-Programs that provide financial assistance to eligible individuals and families so they have easy access to comprehensive and preventive medical coverage. Examples are the AIDS Drug Assistance Program and First Steps.

EIS (Executive Information System)-Supports executive decision making by providing easy access to internal and external business data - in the case of the IHCP, the system used to plan, monitor, and evaluate the State's Medicaid program.

electronic benefits transfer (EBT)-Allows the State to issue food stamps and benefit checks electronically by using plastic Beneficiary ID Cards. Conforms to ANSI Uniform Health Care ID Card Standards.

electronic claims capture (ECC)-The direct transmission of electronic claims over telephone lines to IndianaAIM. ECC uses point-of-sale devices and PCs to verify eligibility, capture claims, apply ProDUR, edit prepayments, and respond to and accept claims submitted online. Also known as electronic claims submission and electronic media claims.

electronic claims management (ECM)-A system that captures claims over telephone lines facilitated by networks, and adjudicates claims submitted by providers online in real time. Paperless claims.

electronic claims submission (ECS)-Claim transmittal via electronic media.

electronic data interchange (EDI)-Standard format for exchanging business data. This usually means X12 and similar variable-length formats for the electronic exchange of data between different companies using networks, such as the Internet. It is sometimes used more broadly to mean any electronic exchange of formatted data.

electronic file interchange (EFI)-Batch-mode enumeration (assigning standard unique identifiers) of multiple providers by a third party. (NPI Final Rule, Page 3448, Federal Register /Vol.69 No.15 / defines bulk enumeration as "mass enumeration of a large number of healthcare providers, all at one time, from a database or file that uniquely identifies them in a way consistent with the identification criteria in this final rule.")

electronic file interchange organization (EFIO)-An organization certified by CMS to submit NPI applications via EFI on behalf of, and with the authorization of, a group of providers.

electronic funds transfer (EFT)-Paying providers for approved claims via electronic transfer of funds from the State directly to providers' accounts.

electronic media claims (EMC)-Claims submitted in electronic format rather than on paper. See ECC, ECS.

Electronic Remittance Advice (ERA)-Any of several electronic formats for explaining payment of healthcare claims. Generally, RAs are submitted to providers in the same media providers use when submitting claims. See RA, NCPDP.

Electronic Remittance Notice (ERN)-A system that enables Medicaid to send remittance advice electronically to providers.

eligibility file-Contains individual records for all persons who are eligible or have been eligible for the IHCP.

Eligibility Verification System (EVS)-Allows providers to check recipient eligibility using a point-of-sale device, online PC access, or automated voice response system.

eligible member-Person certified by the State as qualified for medical assistance, in accordance with the State plans under Title XIX of the Social Security Act, Title V of the Refugee Education Assistance Act, or State law.

eligible providers-Person, organization, or institution approved by the State for participation in the IHCP.

EMC (electronic media claim)-Claims submitted in electronic format rather than on paper. See ECC, ECS.

emergency change request-A request that cannot wait until the next weekly OMPP Operational Effectiveness Team meeting; or a request that the director must know about; or the result of an executive decision to move forward.

emergency medical condition-The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to place the member's health in serious jeopardy; seriously impair bodily functions; or cause serious dysfunction of any bodily organ or part.

emergency services-Covered inpatient and outpatient treatment necessary to evaluate or stabilize an emergency medical condition.

emergency supply-A member's stock of medical materials that will last fewer than five days without resupply; the emergency indicator on the claim is Yes (Y).

Employee Retirement Income Security Act (ERISA)-The Employee Retirement Income Security Act of 1974 (Pub.L. 93-406, 88 Stat. 829, September 2, 1974). A federal statute that protects the interests of participants in employee benefit plans. The act requires employers to report financial and other information to participants; establishes standards of conduct, responsibility, and obligation for fiduciaries of employee benefit plans; and provides employees with remedies and sanctions in cases of wrongdoing.

encounter-A record of medical services rendered to a beneficiary who is enrolled in a participating health plan (HMO) or in a PCCM plan during the date of service. The record includes all services for which the plan incurred financial responsibility. Encounters are priced at the Medicaid value of similar claims, but the reimbursement is zero (see stop-loss). If a service is not covered by the HMO/PCCM, the claim is billed by the provider as a fee-for-service claim. Encounters are sometimes referred to as shadow claims because no money is paid.

encounter claims-Reports of patient interactions with a managed care organization's network. Encounter claims contain details equivalent to those of fee-for-service claims, including information about procedures, diagnoses, places of service, billed amounts, and rendering or billing providers. Sometimes referred to as shadow claims.

encounter data-Reports of individual patient encounters with an MCO's delivery system that contain FSS-equivalent detail as to procedures, diagnoses, place of service, billed amounts, service, and billing providers. Encounter data adjudicates the same way FSS claims do, but does not result in payment, except for claims submitted to report maternal deliveries.

encounter data tables-The method IndianaAIM maintains encounter data. This data is stored on tables separate from FSS claims but does not have an impact on the user's ability to access FFS or encounter data.

enrollee-A Medicaid recipient who is a member of a managed care organization, a Prepaid Inpatient Health Plan, a Prepaid Ambulatory Health Plan, or a Primary Care Case Management plan in a given managed care program.

enrollment application-Paper application that consumers may use to enroll in a managed care program.

enrollment broker-State-contracted entity that facilitates initial member enrollment into health plans. An enrollment broker also performs member-initiated changes to primary medical providers and member disenrollments, and serves as an unbiased source for member education about all aspects of the health plans.

enrollment roster-Twice-monthly reports to managed care organizations and Care Select primary medical providers containing information about members assigned to their panels.

Enrollment Tracking System (ETS)-IndianaAIM function that assigns enrollment tracking numbers that become legacy provider identifiers when providers are enrolled.

enumeration-Assigning standard unique identifiers to healthcare providers and health plans.

envelope-The header, trailer, and sometimes other control segments that define the start and end of individual electronic data interchange messages.

ENVOY-A major vendor of pharmacy computer software and hardware. Provides communication networking between the pharmacy and MMIS for claims processing. These claims are in the NCPDP standard electronic format. See NDC.

EOB (explanation of benefits)-An explanation of claim denial or reduced payment included on the provider's RA. A detailed notice issued to the beneficiary by a third-party claims processor to explain payment or nonpayment of a claim. A three-digit code that prints on the RA to explain why a claim was denied or suspended.

EOMB (explanation of Medicare benefits)-A form provided by IndianaAIM that is sent to members to detail payment or denial of claims submitted by providers for services to members.

A document sent to beneficiaries listing claims processed during the month. Beneficiaries are randomly chosen to receive the list and are asked to review the list to help detect fraud.

EOP (explanation of payment)-Previously used by the IHCP for the Claim Summary Statement. Now called the Remittance Advice or RA. Other insurers continue to use the term for claim statements to providers.

EPO (epoetin alfa)-A drug used to manage anemia in patients with renal disease.

EPO (exclusive provider organization)-An arrangement between a provider network and a health insurance carrier or self-insured employer that requires beneficiaries to forego reimbursement if they do not use designated providers.

epoetin alfa (EPO)-A drug used to manage anemia in patients with renal disease.

EPSDT (Early and Periodic Screening, Diagnosis, and Treatment Program)-A program for Medicaid-eligible recipients under the age of 21 that offers free preventive healthcare services, such as screenings, well-child visits, and immunizations. If medical problems are discovered, the recipient is referred for further treatment. The program's goal is early detection and prevention of conditions that can result in more costly treatment or long-term effects. Also known as HealthWatch.

EQRO (External Quality Review Organization)-A State contractor that coordinates and evaluates quality in the Medicaid program with emphasis in the area of HMO activity.

ERA (electronic remittance advice)-Any of several electronic formats for explaining payment of healthcare claims. Generally, RAs are submitted to providers in the same media providers use when submitting claims. See RA, NCPDP.

ERISA (Employee Retirement Income Security Act)-The Employee Retirement Income Security Act of 1974 (Pub.L. 93-406, 88 Stat. 829, September 2, 1974). A federal statute that protects the interests of participants in employee benefit plans. The act requires employers to report financial and other information to participants; establishes standards of conduct, responsibility, and obligation for fiduciaries of employee benefit plans; and provides employees with remedies and sanctions in cases of wrongdoing.

ERN (electronic remittance notice)-A system that enables Medicaid to send remittance advice electronically to providers.

error code-Digits connected to a claim transaction indicating the nature of an error associated with the claim. An error code can become a rejection code if the error causes the claim to be rejected.

errors-Claims that are suspended before adjudication. Several classifications of errors can exist; for example, claims with data discrepancies or claims held up for investigation of possible third-party liability. During detail system design, users have the option of preventing claims suspended for investigation from being classified as errors.

estimated acquisition cost of drugs (EAC)-A federal pricing requirement for drugs; an approximation of the cost at which most providers can buy drugs in the most frequently purchased package size.

ETS (Enrollment Tracking System)-IndianaAIM function that assigns enrollment tracking numbers that become legacy provider identifiers when providers are enrolled.

event detail table-A file in which the telephone system automatically stores detailed information about all incoming, outgoing, and interflow calls, including agent, trunk, or voice-port identification, and the time and duration of events. These records are written into summary tables at midnight each day.

event inhibit string-Data that will prevent a prescription from being completed, such as information about the patient's age and drug use, the presence of a third drug, and so on.

EVS (Eligibility Verification System)-Allows providers to check recipient eligibility using a point-of-sale device, online PC access, or automated voice response system.

exception-When used in the phrase "posts an exception," it indicates there is data on the claim that fails an edit.

exception code-Digits that indicate there is data on a claim that has caused the claim to fail an edit. Depending on the disposition of the edit on the Claim Edit Disposition Listing, the claim may pay, even with edits posted to it. An exception code can have different dispositions depending on its media type.

exchange code-The first three digits of a local telephone number, such as the "425" in "425-3544."

exclusions-Illnesses, injuries, or other conditions for which there are no benefits. Items or services not covered by a healthcare plan.Managed care primary medical providers barred from receiving new assignments.

exclusive provider organization (EPO)-An arrangement between a provider network and a health insurance carrier or self-insured employer that requires beneficiaries to forego reimbursement if they do not use designated providers.

Executive Information System (EIS)-Supports executive decision making by providing easy access to internal and external business data - in the case of the IHCP, the system used to plan, monitor, and evaluate the State's Medicaid program.

Expanded Food and Nutrition Education Program (EFNEP)-Designed to help audiences with limited resources acquire the knowledge, skills, attitudes, and changed behavior necessary to follow nutritionally sound diets.

expected reimbursement amount-A statistically estimated payment a provider expects to receive for services rendered. It is based on the age and gender mix of the provider's patients and on the actual reimbursement received by the provider's peer group.

expenditures-Issuing checks, disbursing cash, and transferring funds electronically, as reported by the State.

explanation of benefits (EOB)-An explanation of claim denial or reduced payment included on the provider's RA. A detailed notice issued to the beneficiary by a third-party claims processor to explain payment or nonpayment of a claim. A three-digit code that prints on the RA to explain why a claim was denied or suspended.

explanation of Medicare benefits (EOMB)-A form provided by IndianaAIM that is sent to members to detail payment or denial of claims submitted by providers for services to members.

A document sent to beneficiaries listing claims processed during the month. Beneficiaries are randomly chosen to receive the list and are asked to review the list to help detect fraud.

explanation of payment (EOP)-Previously used by the IHCP for the Claim Summary Statement. Now called the Remittance Advice or RA. Other insurers continue to use the term for claim statements to providers.

extended care facility (ECF)-An inpatient institution for the care of patients in nonacute conditions. Most commonly, a long-term care, nursing home, or nursing facility.

External Quality Review Organization (EQRO)-A State contractor that coordinates and evaluates quality in the Medicaid program with emphasis in the area of HMO activity.

extranet-A part of a company's intranet that is extended to users outside the company.

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facility list-List of nursing facilities provided to the auditors that contains current residents in the facility and those residents on leave of absence (LOA) and hospital bedhold status. The term is used synonymously with the nursing facility resident list.

FADS (Fraud And Abuse Detection System)-The process and procedures by which quality, quantity, appropriateness, cost of care, and services provided are evaluated against established standards.

fair hearing-A formal meeting where a Hearings Officer listens to all the facts and then makes a decision based on the law.

fair hearing (ancillary application)-This function provides a means of access and storage for all information associated with Medicaid appeals and enables HP and FSSA staff to efficiently manage the appeals process.

Family and Social Services Administration (FSSA)-The umbrella agency responsible for administering most Indiana public assistance programs.

The Office of Medicaid Policy and Planning (OMPP) is a part of FSSA. However, the OMPP is designated as the single State agency responsible for administering the Indiana Medicaid program.

FSSA consists of, but is not limited to, the following offices or divisions:

CHIP: Office of the Children's Health Insurance Program.
DCS: Division of Children's Services.
DDRS: Division of Disability and Rehabilitative Services.
DFR: Division of Family Resources.
DMHA: Division of Mental Health and Addiction.
IDA: Indiana Division of Aging.
OMPP: Office of Medicaid Policy and Planning (designated as the single State agency responsible for administering the IHCP).

Family Assistance Management Information System (FAMIS)-System used as part of the TANF program.

Family Planning product-A family planning related product is identified by a Therapeutic Class Code, Generic (GTC) = 47 (Contraceptives). Norplant products are separately identified by a GTC = 47 and a Therapeutic Class Code, Specific (GC3) = 3669.

The GTC and GC3 are received from First DataBank (FDB) on the weekly FDB update file and are used to indicate if a NDC is family planning related.

Family Planning Service-Any medically approved diagnosis, treatment, counseling, drugs, supplies, or devices prescribed or furnished by a physician to individuals of child-bearing age for purposes of enabling such individuals to determine the number and spacing of their children.

A medically approved treatment, counseling, drugs, supplies, or devices that are prescribed or furnished by a provider to individuals of child-bearing age for purposes of enabling such individuals to freely determine the number and spacing of their children.

FAMIS (Family Assistance Management Information System)-System used as part of the TANF program.

fatal (critical) record error-A record is rejected due to insufficient information to identify the resident and the type of record.

fatal file error-This occurs when an entire file is rejected due to flaws in the basic structure and integrity of the submission file.

FC (Foster Care)-Services provided to children and families when the court has found the child to be in need of care and the parents are not able to meet the safety and care needs of the child.

FDA (Food and Drug Administration)-A federal agency responsible for the monitoring and regulation of foods and drugs distributed in the United States.

FDB (First DataBank)-The supplier of clinical, financial, and informational data points to the MMIS. A business entity that maintains a database of drug information and sells that information. A 24-hour on-call pharmacist is available.

FDOS (first date of service)-The first date of service used in the claim.

federal employer identification number (FEIN)-Number assigned to a business entity by the federal government for tax purposes. Also called ederal tax identification number (FTIN).

federal financial participation (FFP)-The federal government reimburses the State for a portion of the Medicaid administrative costs and expenditures for covered medical services.

A percentage of state expenditures to be reimbursed by the federal government for the administrative and program costs of the Medicaid program. FFP is calculated as a percentage based on the per capita income of the state compared to the nation. The minimum level of participation is 50 percent.

Federal Information Processing Standards (FIPS)-Under the Information Technology Management Reform Act (Public Law 104-106), the Secretary of Commerce approves standards and guidelines that are developed by NIST for federal computer systems. These standards and guidelines are issued by NIST as FIPS for use government-wide. NIST develops FIPS when there are compelling federal government requirements, such as for security and interoperability, and there are no acceptable industry standards or solutions.

Federal Regulations for computer systems that come under the purview of the Federal Govt. Example: FIPS publication 41 establishes guidelines for implementing the Privacy Act of 1974.

Federal Legend Drug-See Legend Drug.

federal medical assistance percentage (FMAP)-The percentage of federal dollars available to a state to provide Medicaid services. FMAP is calculated annually based on a formula designed to provide a higher federal matching rate to states with lower per capita income.

The portion of the Medicaid program, which is paid by the Federal government.

federal poverty level (FPL)-Family income guidelines set by the federal government for the administration of social service benefits. The state-specific guidelines are adjusted for the cost of living in each state. Financial eligibility for social service programs is often based on a percentage of the FPL. Current FPLs may be accessed at Poverty Guidelines, Research, and Measurement.

The poverty threshold is a statistical measure used to indicate the level of cash income needed by a family to purchase a "minimally adequate" market basket of goods and services. The threshold is adjusted for family size and updated every February for inflation. It is a nationwide standard of poverty.

Federal Register-The Federal Register is the official daily publication for Rules, Proposed Rules, and Notices of Federal agencies and organizations, as well as Executive Orders and other Presidential Documents.

Federal Systems Electronic Commerce-Helps with security, practices, and approval of Web site implementation.

federal tax identification number (FTIN)-Number assigned to a business entity by the federal government for tax purposes. Also called federal employer identification number (FEIN).

federal upper limit (FUL)-The pricing structure associated with maximum allowable cost (MAC) pricing.

The established maximum payment rates for drugs from multiple suppliers as determined by CMS.

Federally Qualified Health Center (FQHC)-A center receiving a grant under the Public Health Services Act or entity receiving funds through a contract with a grantee. These include community health centers, migrant health centers, and healthcare for the homeless. FQHC services are mandated Medicaid services and may include comprehensive primary and preventive services, health education, and mental health services.

A federally funded agency that provides medical services on a sliding fee schedule to the general public.

A publicly funded healthcare network established under the Omnibus Budget Reconciliation Act (OBRA) of 1989 to increase access to medical care for the homeless, the underinsured and uninsured.

fee schedule-A listing of acceptable charges or established allowances, normally representative of either standard or maximum charges, for the listed medical or dental procedures.

fee-for-service (FFS)-Separate payment to a healthcare provider for each medical service rendered to a patient. If spelling out, use hyphens.

FEIN (federal employer identification number)-Number assigned to a business entity by the federal government for tax purposes. Also called federal employer identification number (FEIN).

FFP (federal financial participation)-The federal government reimburses the State for a portion of the Medicaid administrative costs and expenditures for covered medical services.

FFS (fee-for-service)-Separate payment to a healthcare provider for each medical service rendered to a patient. If spelling out, use hyphens.

FFS (fee-for-service) reimbursement-The traditional healthcare payment system, under which physicians and other providers receive a payment for each unit of service they provide.

FI (fiscal intermediary)-.Similar to a fiscal agent. A corporation is designated to have complete responsibility for a government health program, including all data processing functions, program administration, professional relations, and clerical staffing for claims processing.

MACs replace Medicare carriers and fiscal intermediaries beginning in 2005. See Medicare Administrative Contractor.

FID (Fraud Investigation Database)-The FID is a comprehensive nationwide system devoted to the accumulation of Medicare fraud and abuse data and is sued by State Medicaid SUR staff..

field-An on-screen area used for entering specific information, such as a name or extension number, within the telephone system. A field prompt identifies the type of information that belongs in each field.

field audit-A provider's facilities, procedures, records, and books are reviewed for conformance to IHCP standards. A field audit may be conducted regularly, routinely, or on a special basis to investigate suspected misutilization.

field staff-State employees located in the local FSSA office.

field validation-As each field is completed by the data entry operator, its validity is checked and the field is corrected, if necessary.

File Exchange-An Internet data exchange solution that is provided by the IHCP for secure file processing, storage, and transfer.

file maintenance-The periodic updating of master files. For example, adding or deleting employees and customers, making address changes and changing product prices. It does not refer to daily transaction processing and batch processing.

filters-A single condition or combination of predefined conditions used to expedite a query by limiting the search criteria.

Financial Adjustment Reason Codes (ARC)-Two-character alphanumeric codes associated with financial transactions and activities that can increase or decrease a payment.

FIPS (Federal Information Processing Standards)-Under the Information Technology Management Reform Act (Public Law 104-106), the Secretary of Commerce approves standards and guidelines that are developed by NIST for federal computer systems. These standards and guidelines are issued by NIST as FIPS for use government-wide. NIST develops FIPS when there are compelling federal government requirements, such as for security and interoperability, and there are no acceptable industry standards or solutions.

Federal Regulations for computer systems that come under the purview of the Federal Govt. Example: FIPS publication 41 establishes guidelines for implementing the Privacy Act of 1974.

First DataBank (FDB)-The supplier of clinical, financial, and informational data points to the MMIS. A business entity that maintains a database of drug information and sells that information. 24-hour on-call pharmacist is available.

first date of service (FDOS)-The first date of service used in the claim.

First Steps-Indiana's First Steps system provides early intervention for families who have infants and toddlers (birth to age 3) with developmental delays or who show signs of being at risk to have certain delays in the future.

fiscal agent contractor-The entity with whom the State successfully negotiated a contract to perform one or more business functions associated with claims processing and provider payment activities.

The offeror(s) with whom the State has successfully negotiated a contract to perform claims processing and provider payment activities.

fiscal intermediary (FI)-Similar to a fiscal agent. A corporation is designated to have complete responsibility for a government health program, including all data processing functions, program administration, professional relations, and clerical staffing for claims processing.

MACs replace Medicare carriers and fiscal intermediaries beginning in 2005. See Medicare Administrative Contractor.

Fiscal Intermediary Shared System (FISS)-MACs replace Medicare carriers and fiscal intermediaries beginning in 2005. See Medicare Administrative Contractor.

fiscal month-Monthly time interval in a fiscal year.

fiscal year-The designated annual reporting period for an entity:

State of Indiana - July 1 through June 30
Federal - October 1 through September 30
HP - November 1 through October 31

FISS (Fiscal Intermediary Shared System)-MACs replace Medicare carriers and fiscal intermediaries beginning in 2005. See Medicare Administrative Contractor.

flat fee-Reimbursement methodology for revenue codes, which prices all services billed with a specific revenue code a specific rate.

flat rate-Reimbursement methodology in which all providers delivering the same service are paid at the same rate. Also known as a uniform rate.

flowchart-A graphical representation of a process. It represents the entire process from start to finish, showing inputs, pathways and circuits, action or decision points, and ultimately, completion. It can serve as an instruction manual or a tool for facilitating detailed analysis and optimization of workflow and service delivery.

FMAP (Federal Medical Assistance Percentage)-The percentage of federal dollars available to a state to provide Medicaid services. FMAP is calculated annually based on a formula designed to provide a higher federal matching rate to states with lower per capita income.

The portion of the Medicaid program, which is paid by the Federal government.

Focused Medical Review-A process whereby the fiscal agent identifies aberrancies in a provider's Medicare services.

Food and Drug Administration (FDA)-A federal agency responsible for the monitoring and regulation of foods and drugs distributed in the United States.

force field analysis-Identifies force and factors, both restraining and driving, that affect the solution of an issue or problem so that the positives can be reinforced and/or negatives reduced or eliminated.

Form 1261A-State Form 44697, OMPP (Division of Family and Children State Form) 1261A, Certification - Plan of Care for Inpatient Psychiatric Hospital Services Determination of Medicaid Eligibility. Used to provide written certification of need for inpatient psychiatric admissions. Hospitals must submit this form to Medicaid's medical policy contractor for admissions to private psychiatric hospitals. State-owned psychiatric facilities must submit this form to the MMRT. The form is reviewed by the Medicaid policy contractor or the MMRT to determine appropriateness of the inpatient stay.

Form 1702-An appealed LOC decision. The hearing decision by a judge is attached to the form.

Form 1703-Form completed when there is agreement with LOC transfer/discharge recommendations.

Form 1704-Notification of intermediate LOC, following a short-term skilled approval. Usually attached to the 450B, which has short-term determination dates.

Form 450B-State Form 38143 (R5/6-93)/Form 450B/PASRR2A - Physician Certification for Long Term Care Services. Completed by the physician to obtain medical information from the attending physician and determine medical needs for level-of-care for the following:

Admission to and Medicaid reimbursement for nursing facilities

Medicaid reimbursement for intermediate care facilities for the mentally retarded/developmentally disabled

Medicaid home- and community-based services waiver programs

State-funded Community and Home Option to Institutional Care for the Elderly and Disabled program

This form, generally known as the form 450B, may be used by other programs under the Division of Disability, Aging, and Rehabilitative Services.

Form 4B-Indiana Pre-Admission Screening.(PAS)/PASRR Assessment Determination. This is the assessment form received for residents to see if they meet the State criteria for facility placement.

formulary-A listing of drugs and the regulations that govern payment.

Foster Care (FC)-Services provided to children and families when the court has found the child to be in need of care and the parents are not able to meet the safety and care needs of the child.

FOX Systems Inc.-Corporate entity contracted by the CMS to implement the NPI program. See NPPES.

FPL (federal poverty level)-Family income guidelines set by the federal government for the administration of social service benefits. The state-specific guidelines are adjusted for the cost of living in each state. Financial eligibility for social service programs is often based on a percentage of the FPL. Current FPLs may be accessed at http://aspe.hhs.gov/poverty/index.shtml.

FQHC (Federally Qualified Health Center)-A center receiving a grant under the Public Health Services Act or entity receiving funds through a contract with a grantee. These include community health centers, migrant health centers, and healthcare for the homeless. FQHC services are mandated Medicaid services and may include comprehensive primary and preventive services, health education, and mental health services.

A federally funded agency that provides medical services on a sliding fee schedule to the general public.

A publicly funded healthcare network established under the Omnibus Budget Reconciliation Act (OBRA) of 1989 to increase access to medical care for the homeless, the underinsured and uninsured.

fraud-To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced.

Fraud And Abuse Detection System (FADS)-The process and procedures by which quality, quantity, appropriateness, cost of care, and services provided are evaluated against established standards.

fraud investigation database (FID)-The FID is a comprehensive nationwide system devoted to the accumulation of Medicare fraud and abuse data and is sued by State Medicaid SUR staff..

freedom of choice-A state must ensure that Medicaid beneficiaries are free to obtain services from any qualified provider. Exceptions are possible through waivers of Medicaid and special contract options.

front end-First process of claim cycle designed to create claim records, perform edits, and produce inventory reports.

front-end process-All claims system activity that occurs before auditing.

FSSA (Family and Social Services Administration)-The umbrella agency responsible for administering most Indiana public assistance programs.

The Office of Medicaid Policy and Planning (OMPP) is a part of FSSA. However, the OMPP is designated as the single State agency responsible for administering the Indiana Medicaid program.

FSSA consists of, but is not limited to, the following offices or divisions:

CHIP: Office of the Children's Health Insurance Program.
DCS: Division of Children's Services.
DDRS: Division of Disability and Rehabilitative Services.
DFR: Division of Family Resources.
DMHA: Division of Mental Health and Addiction.
IDA: Indiana Division of Aging.
OMPP: Office of Medicaid Policy and Planning (designated as the single State agency responsible for administering the IHCP).

FSSA/DFR Service Center-Tthe official name of the Division of Family Resources (DFR) Call Center

FTIN (federal tax identification number)-Number assigned to a business entity by the federal government for tax purposes. Also called federal employer identification number (FEIN).

FUL (Federal Upper Limit)-The pricing structure associated with maximum allowable cost (MAC) pricing.

The established maximum payment rates for drugs from multiple suppliers as determined by CMS.

full assessment-An MDS assessment containing Sections A-R completed on admission, annually, and for significant changes.

functional acknowledgement-An EDI message that is sent in response to the receipt of an EDI message or packet of messages to notify the sender of the original message that it was received. It acknowledges only the receipt of the message or message packet, and does not imply agreement with or understanding of its content.

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garnishment-A court-ordered attachment, or withholding, of a provider's earnings to pay a debt.

GCN (Generic Code Number)-A unique number representing the generic formulation. The GCN is specific to generic ingredient combination, route of administration, and drug strength, across all dosage forms. The GCN is the same across manufacturers and/or package sizes. The number by itself has no significance, but is useful for online computer applications, such as generic substitution.

The standard generic code for drugs.

General Health, Inc. (GHI)-COBC contractor for CMS to process crossover claims.

general practitioner-A doctor of medicine who generally performs a wide range of medical services as opposed to one who specializes only in certain areas of practice.

Generic Code Number (GCN)-A unique number representing the generic formulation. The GCN is specific to generic ingredient combination, route of administration, and drug strength, across all dosage forms. The GCN is the same across manufacturers and/or package sizes. The number by itself has no significance, but is useful for online computer applications, such as generic substitution.

The standard generic code for drugs.

Generic Code Number Sequence Number (GCN SEQNO)-A unique number representing a generic formulation. Like the GCN, it is specific to the generic ingredient(s), route of administration, and drug strength. Both are the same across manufacturers and/or package sizes. Unlike the GCN, which in some cases may have the same value for different dosage forms, the GCN SEQNO is specific to its dosage form. For example, albuterol inhalers are contained under the same GCN, but the GCN SEQNOs differ between the refill canister and the canister plus inhalation device. The GCN SEQNO is a unique number which cannot be reused. GCNs may be reused if necessary.

generic drug-A chemically equivalent copy designed from a brand name whose patent has expired and is typically less expensive.

A term used in reference to drugs that meet the following criteria:
The product is available from more than one source.
The Average Wholesale Price of the product is significantly lower than the non-generic.
The product is not under patent.
Identified by generic Indicator

Generic Indicator (GI)-Differentiates single-source from multiple-source drugs. Valid values are:

1 = Multiple source
2 = Single source

Geographic Practice Cost Index (GPCI)-Used by Medicare to adjust for variance in operating costs of medical practices located in different parts of the country.

GHI (General Health, Inc.)-COBC contractor for CMS to process crossover claims.

GI (Generic Indicator)-Differentiates single-source from multiple-source drugs.

Valid values are:

1 = Multiple source
2 = Single source

Governor's Planning Council for People with Disabilities (GPCPD)-The Indiana Governor's Council is an independent state agency that facilitates change. Its purpose is to promote public policy, which leads to the independence, productivity, and inclusion of people with disabilities in all aspects of society.

GPCI (Geographic Practice Cost Index)-Used by Medicare to adjust for variance in operating costs of medical practices located in different parts of the country.

GPCPD (Governor's Planning Council for People with Disabilities)-The Indiana Governor's Council is an independent state agency that facilitates change. Its purpose is to promote public policy, which leads to the independence, productivity, and inclusion of people with disabilities in all aspects of society.

grievance (ancillary application)-The grievance application provides a means of access and storage for all information associated with all grievances and enables HP and FSSA staff to efficiently manage the grievance process.

grievance/complaint-A serious written expression of concern about a situation. Grievances can be generated by a beneficiary or provider.
Grievance=formal / Complaints=informal.

gross adjustment-A lump sum adjustment for a provider. A gross adjustment may be positive or negative and is not associated with a specific claim. In the Financial/Fiscal Management system, online entry of gross adjustments is available. Audit trails of all adjustments will be maintained in the system.

Group Model Health Maintenance Organization-A healthcare model involving contracts with physicians organized as a partnership, professional corporation, or other association. The health plan compensates the medical group for contracted services at a negotiated rate, and that group is responsible for compensating its physicians and contracting with hospitals for care of their patients.

group practice-A medical practice in which several providers (case managers with respect to waiver providers) render and bill for services under a single billing provider number.

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hard-copy claim-A claim for services that was submitted on a paper claim form rather than via electronic means; also referred to as paper or manual claim.

Harmony Health Plan-An MCO responsible for statewide coverage for Hoosier Healthwise participants prior to January 1, 2007.

HBP (hospital-based physician)-A physician who performs services in a hospital setting and has a financial arrangement to receive income from that hospital for the services performed.

HCBS (Home and Community-Based Services) or HCBS Waiver Programs-A federal category of Medicaid services, established by Section 2176 of the Social Security Act. HCBS includes: adult day care, respite care, homemaker services, training in activities of daily living skills, and other services that are not normally covered by Medicaid. Services are provided to disabled and aged recipients to allow them to live in the community and avoid being placed in an institution.

Home and Community Based services are for persons with mental retardation or other developmental disabilities are made possible through Medicaid waivers. These services are intended as an alternative to institutional services. Each waiver offers services for a specific group: Head Injury, Technology Assistance, Physical Disability, Frail and Elderly, Developmental Disabilities, and Children with Severe Emotional Disturbance.

Eligible participants in HCBS Waiver programs are eligible for IHCP and receive home or community based services not otherwise reimbursed by the program. Participants in an HCBW program would require institutionalization in the absence of the waiver services. Additional information about waiver services may be found in the IHCP Provider Manual.

HCFA (Health Care Financing Administration)-Previous name of the federal agency in the Department of Health and Human Services that oversees the Medicaid and Medicare programs. Effective August 2001, its name changed to Centers of Medicare & Medicaid Services (CMS).

HCFA-1500-Previous name for the CMS-approved standardized claim form used to bill professional services. Current form is the CMS-1500 version 08-05. Electronic claims are submitted using the 837P transaction.

HCI (Hospital Care for the Indigent)-A program that pays for emergency hospital care for needy persons who are not covered under any other medical assistance program.

HCPCS (Healthcare Common Procedure Coding System)-A uniform healthcare procedural coding system approved for use by CMS. HCPCS includes all subsequent editions and revisions.

HCPCS describes the physician and non-physician patient services covered by the Medicaid and Medicare programs. It is used primarily to report reimbursable services provided to patients.

There are three types of HCPCS codes.

Level 1 includes the CPT-4 codes.
Level 2 includes the alphanumeric codes A through V which CMS maintains for a wide range of services from ambulance trips to hearing aids which are not addressed by the CPT-4 coding.
Level 3 includes the alphanumeric codes W through Z, which are assigned for use by the state agencies.

HCBS-OBRA (Home and Community-Based Services-Omnibus Budget Reconciliation Act)-A waiver of the Medicaid state plan granted under Section 1915(c)(7)(b) of the Social Security Act that allows Indiana to provide community-based services to certain people with developmental disabilities placed in nursing facilities but requiring specialized service according to the PASRR process.

Head Injured Rehabilitation Facility-A facility where beneficiaries with head injuries receive rehabilitation services.

Head Injury Waiver-An HCBS classification for beneficiaries who have sustained head injuries.

header-Identification and summary information at the head (top) of a claim form or report.

This term refers to data on a claim that is not line item specific, but applies to the entire claim. An example of header information would be the provider's name, address, and SSN.

Health and Human Services (HHS)-Also known as DHHS and DHS. See U.S. Department of Health and Human Services or Department of Health and Human Services.

The executive department of the federal government responsible for social and economic security, educational opportunity, national health and child welfare. Specifically, the department is responsible for Medicaid and Medicare Programs. Formerly DHEW.

Health Care Analysis-A division within the fiscal agent that consists of the authorized services unit, the utilization management unit, and the pharmaceutical review unit.

Health Care Financing Administration (HCFA)-Previous name of the federal agency in the Department of Health and Human Services that oversees the Medicaid and Medicare programs. Effective August 2001, its name changed to Centers of Medicare & Medicaid Services (CMS).

health insurance-Includes, but is not limited to, coverage by any healthcare insurer, health maintenance organization, or an employer-administered ERISA plan.

A contract under which a company guarantees payment for specified loss by disease or accidental bodily injury normally by covering a portion of the associated medical costs.

Health Insurance Assistance Program (HIAP)-The Indiana HIAP provides financial assistance that allows eligible people living with HIV easy access to comprehensive medical insurance through the ICHIA. To qualify, individuals must have an income of less than 300 percent of the federal poverty level, be HIV positive, must not have any other medical assistance or insurance, and reside in Indiana for at least three months.

health insurance carrier (HIC), health insurance carrier number (HIC # or HICN), health insurance claim (HIC), health insurance claim number (HIC # or HICN)-Identification number for those patients with Medicare coverage. The HIC # is usually the patient's SSN and an alphabetic suffix that denotes different types of benefits.

Health Insurance Portability and Accountability Act (HIPAA)-The Health Insurance Portability and Accountability Act of 1996 is a set of rules to be followed by health plans, doctors, hospitals, and other healthcare providers. HIPAA took effect April 14, 2003. In the healthcare and medical profession, the great challenge that HIPAA has created is the assurance that all patient account handling, billing, and medical records are HIPAA compliant.

A federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of healthcare data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for healthcare patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable healthcare information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191. Accountability Act of 1996.

Health Insurance Premium Payment (HIPP)-A program where Medicaid-eligible beneficiaries may receive insurance premium assistance using Medicaid funds when it is determined cost-effective to purchase group health insurance.

health maintenance organization (HMO)-Organization that delivers and manages health services under a risk-based arrangement. The HMO usually receives a monthly premium or capitation payment for each person enrolled, which is based on a projection of what the typical patient will cost. If enrollees cost more, the HMO suffers losses. If the enrollees cost less, the HMO profits. This gives the HMO incentive to control costs.

A prepaid cost-effective health plan that provides a range of preventative and maintenance services in return for a fixed monthly premium that entitles the enrollees to a predetermined set of basic and supplemental services. A healthcare providing organization, which charges a flat fee per month (Capitation) per person, enrolled. The services provided are defined by contract and generally are comprehensive. HMO enrollment is an alternative form of healthcare delivery that is offered to Medicaid beneficiaries.

Health Plan-An individual or group plan that provides, or pays the cost of, medical care (as such term is defined in section 2791 of the Public Health Service Act). Such term includes the following, and any combination thereof:

"(A) A group health plan (as defined in section 2791(a) of the Public Health Service Act), but only if the plan--
"(i) has 50 or more participants (as defined in section 3(7) of the Employee Retirement Income Security Act of 1974); or
"(ii) is administered by an entity other than the employer who established and maintains the plan.
"(B) A health insurance issuer (as defined in section 2791(b) of the Public Health Service Act).
"(C) A health maintenance organization (as defined in section 2791(b) of the Public Health Service Act).
"(D) Part A or part B of the Medicare program under title XVIII.
"(E) The Medicaid program under title XIX.
"(F) A Medicare supplemental policy (as defined in section 1882(g)(1)).
"(G) A long-term care policy, including a nursing home fixed indemnity policy (unless the Secretary determines that such a policy does not provide sufficiently comprehensive coverage of a benefit so that the policy should be treated as a health plan).
"(H) An employee welfare benefit plan or any other arrangement which is established or maintained for the purpose of offering or providing health benefits to the employees of 2 or more employers.
"(I) The healthcare program for active military personnel under title 10, United States Code.
"(J) The veterans healthcare program under chapter 17 of title 38, United States Code.
"(K) The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), as defined in section 1072(4) of title 10, United States Code.
"(L) The Indian health service program under the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.).
"(M) The Federal Employees Health Benefit Plan under chapter 89 of title 5, United States Code.

Health Plan Employer Data and Information Set (HEDIS)-A core set of performance measures developed for employers to use in assessing health plans.

Used to measure a plan's performance. Utilized in Quality Assurance for Managed Care. HEDIS and HEDIS and Compliance Audit are registered trademarks of the National Committee for Quality Assurance (NCQA). NCQA encourages and promotes the use of performance measures that comprise HEDIS. HEDIS Compliance Audit is a rigorous process for evaluating the accuracy and validity of plan-reported performance results.

A federal standard for electronic data interchange (EDI) for Medicaid Managed Care programs.

Health Plan ID-See National Payor ID.

Health Professions Bureau (HPB) -Replaced by Indiana Professional Licensing Agency (IPLA).

Health Resources and Services Administration (HRSA)-A division of the U.S. Department of Health and Human Services, HRSA provides national leadership, program resources, and services needed to improve access to culturally competent, quality healthcare.

health service provider in psychology (HSPP)-A psychologist that possesses a doctoral degree in clinical psychology, counseling psychology, school psychology, or another applied health service area of psychology, granted from an institution of higher learning recognized by the board and with a degree program approved by the board. The educational and applied experience must be in accordance with IC 25-33-1-5.1 and IC 25-33-2.

healthcare clearinghouse-This is an entity that processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction, or that receives a standard transaction from another entity and processes or facilitates the processing of that information into nonstandard format or nonstandard data content for a receiving entity.

Healthcare Common Procedure Coding System (HCPCS)-A uniform healthcare procedural coding system approved for use by CMS. HCPCS includes all subsequent editions and revisions.

HCPCS describes the physician and non-physician patient services covered by the Medicaid and Medicare programs. It is used primarily to report reimbursable services provided to patients.

There are three types of HCPCS codes.

healthcare provider-A person who is trained and licensed to give healthcare. Also, a place that is licensed to give healthcare. Doctors, nurses, and hospitals are examples of healthcare providers.

See 45CRF 160.13 Healthcare provider means a provider of services (as defined in section 1861(u) of the Act, 42 U.S.C. 1395x(u)), a provider of medical or health services (as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s)), and any other person or organization who furnishes, bills, or is paid for healthcare in the normal course of business.

HealthWatch-Indiana's preventive care program for IHCP members younger than 21 years old. Also known as EPSDT.

Healthwise (Hoosier Healthwise [HHW])-Indiana's healthcare program for children, low-income families, and pregnant women. It consists of the federal- and state-funded programs of Medicaid and CHIP and is administered by the State to provide reimbursement for reasonable and necessary medical care for persons meeting both medical and financial eligibility requirements. Different benefit packages are available to the various populations eligible for Hoosier Healthwise, primarily Package A (Standard), Package B (Pregnancy), and Package C (CHIP). This population is administered through an RBMC program, managed by the State's capitated MCO plans. FFS is the delivery system for carved-out services. For more information, visit http://www.healthcareforhoosiers.com.

Healthy Indiana Plan (HIP)-A program sponsored by the state of Indiana that provides more affordable healthcare choices to thousands of otherwise uninsured individuals throughout Indiana. HIP provides health insurance for uninsured adult Hoosiers between the ages of 19 and 64 whose income is up to 200 percent of the federal poverty level (FPL), and who are not otherwise eligible for Medicaid. Unlike many other government-sponsored programs, parents and childless adults can participate.

HEDIS (Health Plan Employer Data and Information Set)-A core set of performance measures developed for employers to use in assessing health plans.

A federal standard for electronic data interchange (EDI) for Medicaid Managed Care programs.

HHA (home health agency)-An agency or organization approved as a home health agency under Medicare and designated by ISDH as a Title XIX Home Health Agency.

HHPD (Hoosier Healthwise Program for Persons with Disabilities and Chronic Illnesses)-Formerly Managed Care Program for Persons with Disabilities MCPD.

HHS (Health and Human Services)-Also known as DHHS and DHS. See U.S. Department of Health and Human Services or Department of Health and Human Services.

HHW (Hoosier Healthwise)-Indiana's healthcare program for children, low-income families, and pregnant women. It consists of the federal- and state-funded programs of Medicaid and CHIP and is administered by the State to provide reimbursement for reasonable and necessary medical care for persons meeting both medical and financial eligibility requirements. Different benefit packages are available to the various populations eligible for Hoosier Healthwise, primarily Package A (Standard), Package B (Pregnancy), and Package C (CHIP). This population is administered through an RBMC program, managed by the State's capitated MCO plans. FFS is the delivery system for carved-out services. For more information, visit http://www.healthcareforhoosiers.com.

HIAP (Health Insurance Assistance Program)-The Indiana HIAP provides financial assistance that allows eligible people living with HIV easy access to comprehensive medical insurance through the ICHIA. To qualify, individuals must have an income of less than 300 percent of the federal poverty level, be HIV positive, must not have any other medical assistance or insurance, and reside in Indiana for at least three months.

HIC (health insurance carrier or health insurance claim), HIC # (health insurance carrier number or health insurance claim number), or HICN (health insurance carrier number or health insurance claim number)-Identification number for those patients with Medicare coverage. The HIC # is usually the patient's SSN and an alphabetic suffix that denotes different types of benefits.

high risk register (HRR)-In relation to audiological screening

HIP (Healthy Indiana Plan)-A program sponsored by the state of Indiana that provides more affordable healthcare choices to thousands of otherwise uninsured individuals throughout Indiana. HIP provides health insurance for uninsured adult Hoosiers between the ages of 19 and 64 whose income is up to 200 percent of the federal poverty level (FPL), and who are not otherwise eligible for Medicaid. Unlike many other government-sponsored programs, parents and childless adults can participate.

HIPAA (Health Insurance Portability and Accountability Act of 1996)-The Health Insurance Portability and Accountability Act of 1996 is a set of rules to be followed by health plans, doctors, hospitals, and other healthcare providers. HIPAA took effect April 14, 2003. In the healthcare and medical profession, the great challenge that HIPAA has created is the assurance that all patient account handling, billing, and medical records are HIPAA compliant.

HIPAA Compliant-The policies and procedures developed to achieve compliance with the HIPAA Privacy and Security Rules.

HIPP (Health Insurance Premium Payment)-A program where Medicaid-eligible beneficiaries may receive insurance premium assistance using Medicaid funds when it is determined cost-effective to purchase group health insurance.

HME (home medical equipment)-Technologically sophisticated medical devices that may be used in a residence, IC 25-26-21.

HMO (health maintenance organization)-Organization that delivers and manages health services under a risk-based arrangement. The HMO usually receives a monthly premium or capitation payment for each person enrolled, which is based on a projection of what the typical patient will cost. If enrollees cost more, the HMO suffers losses. If the enrollees cost less, the HMO profits. This gives the HMO incentive to control costs.

HMS-Subcontracted by HP, HMS performs pay and chase recovery services for the IHCP. Sources of recovery include commercial insurance, TRICARE (FEP), Medicare and provider self-audits. HMS also provides third-party resource updates to HP for enrolled IHCP members. Services provided by HMS ensure the IHCP is the payor of last resort.

HMS is the subcontractor of HP for performing postpayment recovery functions.

Home and Community Care for the Functionally Disabled-An optional state plan benefit that allows states to provide HCBS to functionally disabled individuals. In Indiana, this optional benefit is used by ISDH to provide personal care services to people who have income in excess of SSI limitations but who would be financially qualified in an institution. Also known as the Frail Elderly provision, although Indiana can serve people of any age under this provision.

Home and Community-Based Services (HCBS) Waiver Programs or HCBS (Home and Community-Based Services)-A federal category of Medicaid services, established by Section 2176 of the Social Security Act. HCBS includes adult day care, respite care, homemaker services, training in activities of daily living skills, and other services that are not normally covered by Medicaid. Services are provided to disabled and aged members to allow them to live in the community and avoid being placed in an institution.

Home and Community-Based Services-Omnibus Budget Reconciliation Act (HCBS-OBRA)-A waiver of the Medicaid state plan granted under Section 1915(c)(7)(b) of the Social Security Act that allows Indiana to provide community-based services to certain people with developmental disabilities placed in nursing facilities but requiring specialized service according to the PASRR process.

home health agency (HHA)-An agency or organization approved as a home health agency under Medicare and designated by ISDH as a Title XIX Home Health Agency.

Home Health Care Services-Visits ordered by a physician authorized by the DHS and provided to homebound members by licensed, registered, and practical nurses and nurses' aids from authorized home healthcare agencies. These services include medical supplies, appliances, and DME suitable for use in the home.

home medical equipment (HME)-Technologically sophisticated medical devices that may be used in a residence, IC 25-26-21.

Hoosier Healthwise (HHW)-Indiana's healthcare program for children, low-income families, and pregnant women. It consists of the federal- and state-funded programs of Medicaid and CHIP and is administered by the State to provide reimbursement for reasonable and necessary medical care for persons meeting both medical and financial eligibility requirements. Different benefit packages are available to the various populations eligible for Hoosier Healthwise, primarily Package A (Standard), Package B (Pregnancy), and Package C (CHIP). This population is administered through an RBMC program, managed by the State's capitated MCO plans. FFS is the delivery system for carved-out services. For more information, visit http://www.healthcareforhoosiers.com.

Hoosier Healthwise Program for Persons with Disabilities and Chronic Illnesses (HHPD)-Formerly Managed Care Program for Persons with Disabilities MCPD.

Hoosier Healthwise Welcome Letter-The welcome letter serves as the member's notification of enrollment in the Hoosier Healthwise program. The letter confirms the member's PMP selection and service location address assignment and provides a contact number for any questions regarding the member assignment.

HoosierRx-A qualified State Pharmaceutical Assistance Program. Program ended December 31, 2005.

hospice-An organization that furnishes inpatient, outpatient, and home healthcare for the terminally ill.

hospital-A healthcare institution whose primary function is to provide inpatient services for a variety of surgical and nonsurgical medical conditions. Hospitals are classified by length of stay, teaching or non-teaching, major type of services, and by control.

Hospital Care for the Indigent (HCI)-A program that pays for emergency hospital care for needy persons who are not covered under any other medical assistance program.

Hospital Insurance Program (Part A)-The compulsory portion of Medicare that automatically enrolls all persons 65 years of age or older, entitled to railroad retirement and eligible for disability for more than two years, and insured workers and their dependents requiring dialysis or kidney transplants.

hospital-based physician (HBP)-A physician who performs services in a hospital setting and has a financial arrangement to receive income from that hospital for the services performed.

HP-,The Indiana medical assistance programs' fiscal agent..

HPB (Health Professions Bureau)-Replaced by Indiana Professional Licensing Agency (IPLA).

HPSB (Health Professions Service Bureau)-Same as HPB. Replaced by Indiana Professional Licensing Agency (IPLA)

HRR (high risk register)-In relation to audiological screening.

HRSA (Health Resources and Services Administration)-A division of the U.S. Department of Health and Human Services, HRSA provides national leadership, program resources, and services needed to improve access to culturally competent, quality healthcare.

HSPP (health service provider in psychology)-A psychologist that possesses a doctoral degree in clinical psychology, counseling psychology, school psychology, or another applied health service area of psychology, granted from an institution of higher learning recognized by the board and with a degree program approved by the board. The educational and applied experience must be in accordance with IC 25-33-1-5.1 and IC 25-33-2.

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IAC (Indiana Administrative Code)-Indiana Code (IC) translated to administrative procedures by the responsible State governmental agency.

IBNR (incurred but not received)-Claim.

IC (Indiana Code)-Indiana laws. State government agency procedures

ICD (International Classification Of Diseases)-A classification and coding structure of diseases used by the healthcare community to describe patients' conditions and illness, and to facilitate the collection of statistical and historical data.

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification)-Standardized diagnosis codes used on claims submitted by providers.

ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification)-Standardized diagnosis codes used on claims submitted by providers.

A three-volume coding manual that contains the diagnosis codes used in coding claims, as well as the procedure codes used in billing for services performed in a hospital setting.

ICDMP (Indiana Chronic Disease Management Program)-A program established by the OMPP for persons with diabetes, asthma, cardiovascular disease, congestive heart failure, hypertension, and members who are at high risk of chronic disease.

ICES (Indiana Client Eligibility System)-Caseworkers in the county offices of the Division of Family and Children use this system to help determine applicants' eligibility for medical assistance, food stamps, and Temporary Assistance for Needy Families (TANF). Medicaid and CHIP eligibility data in IndianaAIM is provided by ICES.

ICF (intermediate care facility)-Institution providing health-related care and services to individuals who do not require the degree of care provided by a hospital or skilled nursing home, but who, because of their physical or mental condition, require services beyond the level of room and board.

ICF/MR (intermediate care facility for the mentally retarded)-Provides residential care treatment for IHCP-eligible, mentally retarded individuals.

Facilities that have met state licensure standards and that provide habilitation-related care and services, prescribed by a physician, in conjunction with active treatment programming for beneficiaries who are mentally retarded and who have related health and physical conditions.

ICHIA (Indiana Comprehensive Health Insurance Association)-A health insuring organization for special situations

ICLPPP (Indiana Childhood Lead Poisoning Prevention Program)-A division of the ISDH mandated to increase screening and follow-up care of children in need of protection and to help communities pursue the most appropriate approach to the prevention of childhood lead poisoning.

ICN (internal control number)-A unique number assigned to claims, attachments, or adjustments received in the fiscal agent contractor's mailroom or to each transaction in IndianaAIM.

ICN/DCN (internal control number; document control number)-Number assigned to claims, attachments, or adjustments received in the fiscal agent contractor's mailroom.

ICU (Intensive Care Unit)-Level of Care rendered by the attending physician to a critically ill patient requiring additional time and study beyond regular medical care.

IDDARS (Indiana Division of Disability, Aging, and Rehabilitative Services)-State agency that exists to inform, protect, and serve older adults and individuals with disabilities and their families, in need of human services, resources, or support, to attain employment and self-sufficiency or to maintain independence. Previous name for DDRS and IDA.

identical, related, or similar drugs (IRS)-In relation to LTE drugs.

IDOA (Indiana Department of Administration)-Conducts State financial operations including: purchasing, financial management, claims management, quality assurance, payroll for State staff, institutional finance, and general services such as leasing and human resources.

IEMS (Indiana Emergency Medical Service)-Pre-hospital emergency care system regulated by the Indiana EMS Commission, a governor-appointed board whose policies and procedures are supported by the Emergency Medical Services Section of the Indiana Department of Homeland Security.

IEP (individual education plan)-Relates to the First Steps Early Intervention System, as well as relating to the Division of Exceptional Learners.

IFSP (Individual Family Service Plan)-In relation to the First Steps Early Intervention System.

Documents and guides the early intervention process for children with disabilities and their families. The IFSP is the vehicle through which effective early intervention is implemented in accordance with Part C of the IDEA. It contains information about the services necessary to facilitate a child's development and enhance the family's capacity to facilitate the child's development. Through the IFSP process, family members and service providers work as a team to plan, implement, and evaluate services tailored to the family's unique concerns, priorities, and resources.

IG (Implementation Guide)-A document explaining the proper use of a standard for a specific business purpose. The X12N HIPAA IGs are the primary reference documents used by those implementing the associated transactions, and are incorporated into the HIPAA regulations by reference.

A publication that identifies and defines the EDI messages used in a particular industry or application. The document indicates how the information in those messages should be presented on a segment-by-segment, and data-element-by-data-element basis, as well as identifying which segments and data elements are needed, which ones need not be used, and what code values will be expected in the application of that particular message.

IHCP (Indiana Health Coverage Programs)-The IHCP receives federal and state funds to allow reimbursement for reasonable and necessary medical care for persons meeting eligibility requirements. Each state administers its own program within broad federal guidelines. In Indiana, the IHCP is administered by the Indiana Family and Social Services Administration (FSSA), Office of Medicaid Policy and Planning (OMPP). Indiana Health Coverage Programs include the following:

590 Program.
Hoosier Healthwise (including CHIP).
Traditional Medicaid.
Indiana Care Select.
Healthy Indiana Plan (HIP).

IHCP Companion Guides-Additional reference documents or guides that contain general information, or electronic standards and trading partner testing for providers and EDI vendors in developing software for electronic data transmissions, and so forth, and are used in addition to other IHCP manuals.

IHCP legacy provider number-Provider numbers assigned by the IHCP.

IIHI (individually identifiable health information)-Part of the Privacy Rule of HIPAA. Any health information, including demographic information, that is created or received by a covered entity and relates to the physical or mental health of an individual, the provision of healthcare to an individual, or payment for the provision of healthcare. Also referred to as PHI.

imaging-A method of electronically capturing a representation of a form, whether it is a claim or other piece of correspondence, to allow rapid retrieval and processing of the source document copy.

IMCS (Indiana Motor Carrier Services)-The Indiana Intrastate Passenger Authority is administered by the Indiana Department of Revenue. Motor carrier professionals obtain permits to transport passengers through this department.

IME (independent medical examination)-Examinations performed by a physician who is not involved in the patient's care for the purpose of clarifying medical and job-related issues.

IMF (Indiana Medical Foundation)-Non-profit organization contracted by the DHS for the daily review and correction of abstracts submitted by all IHCP hospitals in Indiana.

IMFCU (Indiana Medicaid Fraud Control Unit)-Investigative branch of the Attorney General's Office. IMFCU conducts investigations into Medicaid provider fraud, misuse of Medicaid funds, and patient abuse or neglect in Medicaid facilities. The unit presents the case to the state or federal prosecutors for appropriate action. See also MFCU.

Implementation Guide (IG)-A document explaining the proper use of a standard for a specific business purpose. The X12N HIPAA IGs are the primary reference documents used by those implementing the associated transactions, and are incorporated into the HIPAA regulations by reference.

IMS (Issue Management System)-Web-based tool developed as an add-on module to Project Workbook. This application is used by the OMPP, HP, and HCE to log identified issues for IndianaAIM.

A formal system for the identification, logging, and prioritization of issues; determination of issue resolution actions; monitoring and control of assigned issue resolution actions; and closure of project issues. The primary goals of Issue Management are to ensure that:

Issues are identified, evaluated, and assigned for resolution.

Issue resolutions determined to be modifications, enhancements or defects of a application or system will go through the change management process.

Issue resolutions or decisions are documented and communicated to all affected parties.

The Issue Management process brings visibility to the issue, accountability as to how it is acted upon, and its timely resolution. Analysis of the issue provides data and understanding for a more informed decision.

Recording and reviewing issues ensures that all who need to know have access to the issues knowledge base via a desktop tool. Well-documented issue descriptions, resolutions, and action plans are key to successful issue management.

IN XIX (Indiana Title XIX)-Medicare Program for the state of Indiana.

incurred but not received (IBNR)-Claim.

indemnity insurance-Insurance product in which beneficiaries are allowed total freedom to choose their healthcare providers. Those providers are reimbursed a set fee each time they deliver a service. See fee-for-service.

Independent Living Counselor-Provides case management-type services to beneficiaries on the HCBS/PD Waiver and enters a Plan of Care in the PreCert system for Prior Authorization.

independent medical examination (IME)-Examinations performed by a physician who is not involved in the patient's care for the purpose of clarifying medical and job-related issues.

Indiana Administrative Code (IAC)-Indiana Code (IC) translated to administrative procedures by the responsible State governmental agency.

Indiana Advanced Information Management (IndianaAIM)-The State's current Medicaid Management Information System (MMIS).

Indiana Breast and Cervical Cancer Program-A comprehensive, nationwide public health program to increase early detection of breast and cervical cancer through early screenings with an emphasis on reaching older, low income women.

Indiana Childhood Lead Poisoning Prevention Program (ICLPP)-A division of the ISDH mandated to increase screening and follow-up care of children in need of protection and to help communities pursue the most appropriate approach to the prevention of childhood lead poisoning.

Indiana Chronic Disease Management Program (ICDMP)-A program established by the OMPP for persons with diabetes, asthma, cardiovascular disease, congestive heart failure, hypertension, and members who are at high risk of chronic disease.

Indiana Client Eligibility System (ICES)-Caseworkers in the county offices of the Division of Family and Children use this system to help determine applicants' eligibility for medical assistance, food stamps, and Temporary Assistance for Needy Families (TANF). Medicaid and CHIP eligibility data in IndianaAIM is provided by ICES.

Indiana Code (IC)-Indiana laws. State government agency procedures.

Indiana Comprehensive Health Insurance Association (ICHIA)-A health insuring organization for special situations.

Indiana Department of Administration (IDOA)-Conducts State financial operations including: purchasing, financial management, claims management, quality assurance, payroll for State staff, institutional finance, and general services such as leasing and human resources.

Indiana Division of Disability, Aging, and Rehabilitative Services (IDDARS)-State agency that exists to inform, protect, and serve older adults and individuals with disabilities and their families, in need of human services, resources, or support, to attain employment and self-sufficiency or to maintain independence. Previous name for DDRS and IDA.

Indiana Emergency Medical Service (IEMS)-Pre-hospital emergency care system regulated by the Indiana EMS Commission, a governor-appointed board whose policies and procedures are supported by the Emergency Medical Services Section of the Indiana Department of Homeland Security.

Indiana Family and Social Service Administration (FSSA)-The State agency responsible for the coordination and administration of social service programs in the state of Indiana. The OMPP, under FSSA, is the single State agency responsible for the administration of the IHCP. Also referred to as FSSA.

The umbrella agency responsible for administering many of Indiana's social services programs, including those administered by the Office of Medicaid Policy and Planning and the Office of the Children's Health Insurance Program.

Indiana Health Coverage Programs (IHCP)-The IHCP receives federal and state funds to allow reimbursement for reasonable and necessary medical care for persons meeting eligibility requirements. Each state administers its own program within broad federal guidelines. In Indiana, the IHCP is administered by the Indiana Family and Social Services Administration (FSSA), Office of Medicaid Policy and Planning (OMPP). Indiana Health Coverage Programs include the following:

590 Program.
Hoosier Healthwise (including CHIP).
Traditional Medicaid.
Indiana Care Select.
Healthy Indiana Plan (HIP)

Indiana Medicaid Fraud Control Unit (IMFCU) or Medicaid Fraud Control Unit (MFCU)-Investigative branch of the Attorney General's Office. IMFCU conducts investigations into Medicaid provider fraud, misuse of Medicaid funds, and patient abuse or neglect in Medicaid facilities. The unit presents the case to the state or federal prosecutors for appropriate action.

Indiana Medical Foundation (IMF)-Non-profit organization contracted by the DHS for the daily review and correction of abstracts submitted by all IHCP hospitals in Indiana.

Indiana Medical Review Program-IMRP. Program administered by the IMF to ensure the medical necessity of hospitalization and surgery.

Indiana Motor Carrier Services (IMCS)-The Indiana Intrastate Passenger Authority is administered by the Indiana Department of Revenue. Motor carrier professionals obtain permits to transport passengers through this department.

Indiana Perinatal Network (IPN)-Alliance of individuals and organizations that serves to promote and protect the health and safety of mothers, babies, and families through consensus building, education, and collaborative partnerships among public and private organizations.

IPN fosters partnerships among community groups, nonprofit organizations, professional associations, businesses, and government agencies. These collaborations bring expertise and strength to local and state perinatal efforts to achieve a mutual vision for Indiana's mothers and babies.

Indiana Pharmacists Alliance (IPA)-The profession's advocacy representative for the practice of pharmacy in Indiana.

Indiana pre-admission screening (IPAS)-A nursing home and community-based services program implemented January 1, 1987, which is designed to screen a member's potential for remaining in the community and receiving community-based services as an alternative to nursing home placement.

Indiana Prescription Drug Program (IPDP)-A program implementing the recommendations of the prescription drug advisory committee to provide access to needed pharmaceuticals to ensure the health and welfare of Indiana's low-income senior citizens.

Indiana Professional Licensing Agency (IPLA)-Provides administrative support services to Indiana's professional licensing boards and commissions. Also, provides a process for licensing regulated professionals in Indiana.

Indiana State Board of Health (ISBOH)-Currently known as the Indiana State Department of Health.

Indiana State Department of Health (ISDH)-The State agency responsible for promotion of health, providing guidance on public health issues, ensuring the quality of health facilities and programs, and the administration of certain health programs. The Bureau of Family Health Services is the bureau within the ISDH organization charged with the administration of the Children's Special Health Care Services Division (CSHCS) as well as The Maternal and Child Health Division (MCH) and the Division of Women, Infants and Children (WIC). This agency is also responsible for surveying and certifying hospitals, long-term care facilities, home health agencies, FQHCs, and ICFs/MR. ISDH also maintains the database, CDMS - Chronic Disease Management System for the Indiana Chronic Disease Management Program.

Formerly known as Indiana State Board of Health (ISBOH).

Indiana Title XIX (IN XIX)-Medicare Program for the state of Indiana.

IndianaAIM (Indiana Advanced Information Management)-The State's current Medicaid Management Information System (MMIS).

IndianaAIM number-A unique number assigned to all Indiana Medicaid-certified nursing facilities. The number is referred to on the MDS 2.0 as the State facility provider number.

Indirect-care component-This is one of four case mix components used to calculate rates. It includes allowable dietary services and supplies, raw food, patient laundry services and supplies, patient housekeeping services and supplies, plant operations services and supplies, utilities, social services and supplies, and activity services and supplies.

The other three components are: administrative, capital, and direct-care.

individual education plan (IEP)-Relates to the First Steps Early Intervention System, as well as relating to the Division of Exceptional Learners.

Individual Family Service Plan (IFSP)-In relation to the First Steps Early Intervention System.

Individual Practice Association (IPA)-A model health maintenance organization (HMO). A healthcare model that contracts with an entity, which in turn contracts with physicians, to provide healthcare services in return for a negotiated fee. Physicians continue in their existing individual or group practices and are compensated on a per capita, fee schedule, or fee-for-service (FFS) basis.

Individual State Agreement-An agreement between a state and a labeler authorized or approved by CMS as meeting the requirements specified in Section 1927(a)(1) or (a)(4) of the Act. Amendments or other changes to agreements under 1927(a)(4) shall not be included in this definition unless specifically accepted by CMS. An existing agreement that met these requirements as of the date of enactment of P.L. No. 101-508 (November 5, 1990), can be modified to give a greater rebate percentage.

individually identifiable health information (IIHI)-Part of the Privacy Rule of HIPAA. Any health information, including demographic information, that is created or received by a covered entity and relates to the physical or mental health of an individual, the provision of healthcare to an individual, or payment for the provision of healthcare. Also referred to as PHI.

Initiating Clerk ID-The ID of the clerk who initiated the claim adjustment online. The Financial system tracks this clerk ID as well as subsequent clerks who work on this adjustment by capturing and storing these IDs.

inquiry-Type of online screen programmed to display rather than enter information. Used to research information about members, providers, claims adjustments, and cash transactions.

inquiry mode-A window mode where the user is viewing data as the result of an inquiry rather than having accessed the specific window to add, change, or delete data from certain financial records and/or claims. Inquiry mode allows flow between the various parts of the system but does not allow changes to the data being viewed.

INsite-INsite is the Waiver Provider and Member Information System.

inspection of care (IOC)-A core contract function reviewing the care of residents in psychiatric hospitals and ICFs/MR. The review process serves as a mechanism to ensure the health and welfare of institutionalized residents.

Institute of Medicine (IOM)-The institute provides information and advice concerning health and science policy.

institution-An entity that provides medical care and services other than that of a professional person. A business other than a private doctor or a pharmacy.

Institution for mental disease-An institution of 17 beds or more, which provides diagnosis, treatment, and nursing care of persons with mental illness. Individuals confined to an IMD require more intensive diagnosis and treatment than individuals in an ICF/MR. Also, mental retardation is only one form of mental illness. An IMD must be capable of comprehensive care for the most difficult patients. Medicaid funds cannot be used for IMD care, but can be used for ICFs.

Integrated Service Delivery-Division of the FSSA responsible for the investigation of reports of child abuse, monitoring private contractors who provide foster care and adoption services, an maintaining a childcare network. They are also responsible for Adult Protective Services (APS).

integrated test facility (ITF)-A copy of the production version of IndianaAIM used for testing any maintenance and modifications before implementing changes in the production system.

intensive care-Level of Care rendered by the attending physician to a critically ill patient requiring additional time and study beyond regular medical care.

Intensive Care Unit (ICU)-Level of Care rendered by the attending physician to a critically ill patient requiring additional time and study beyond regular medical care.

interactive request-An interactive request requires immediate processing. The requester waits until the store/retrieve request completes and receives a response from Unite storager, which indicates the success or failure of the request. Interactive requests are placed immediately at the top of the request queue, and, therefore, have priority over batch requests.

interim-A billing that is only for a portion of the patient's continuous complete stay in an inpatient setting.

intermediary-Private insurance organizations under contract with the government handling Medicare claims from hospitals, skilled nursing facilities, and home health agencies.

A public or private insurance organization under contract with the government to handle claims from hospitals, skilled nursing facilities and home health agencies (Part A Medicare).

MACs replace Medicare carriers and fiscal intermediaries beginning in 2005. See Medicare Administrative Contractor.

intermediate care facility (ICF)-Institution providing health-related care and services to individuals who do not require the degree of care provided by a hospital or skilled nursing home, but who, because of their physical or mental condition, require services beyond the level of room and board.

intermediate care facility for the mentally retarded (ICF/MR)-Provides residential care treatment for IHCP-eligible, mentally retarded individuals.

internal control number (ICN)-A unique number assigned to claims, attachments, or adjustments received in the fiscal agent contractor's mailroom or to each transaction in IndianaAIM.

internal control number/document control number (ICN/DCN)-Number assigned to claims, attachments, or adjustments received in the fiscal agent contractor's mailroom.

International Classification Of Diseases (ICD)-A classification and coding structure of diseases used by the healthcare community to describe patients' conditions and illness, and to facilitate the collection of statistical and historical data.

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)-Standardized diagnosis codes used on claims submitted by providers.

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)-Standardized diagnosis codes used on claims submitted by providers.

A three-volume coding manual that contains the diagnosis codes used in coding claims, as well as the procedure codes used in billing for services performed in a hospital setting.

intranet-An electronic communications network that connects computer networks and organizational computer facilities within an organization.

IOC (inspection of care)-A core contract function reviewing the care of residents in psychiatric hospitals and ICFs/MR. The review process serves as a mechanism to ensure the health and welfare of institutionalized residents.

IOM (Institute of Medicine)-The institute provides information and advice concerning health and science policy

IPA (Indiana Pharmacists Alliance)-The profession's advocacy representative for the practice of pharmacy in Indiana.

IPA (Individual Practice Association)-A model health maintenance organization (HMO). A healthcare model that contracts with an entity, which in turn contracts with physicians, to provide healthcare services in return for a negotiated fee. Physicians continue in their existing individual or group practices and are compensated on a per capita, fee schedule, or fee-for-service (FFS) basis.

IPAS (Indiana pre-admission screening)-A nursing home and community-based services program implemented January 1, 1987, which is designed to screen a member's potential for remaining in the community and receiving community-based services as an alternative to nursing home placement.

IPDP (Indiana Prescription Drug Program)-A program implementing the recommendations of the prescription drug advisory committee to provide access to needed pharmaceuticals to ensure the health and welfare of Indiana's low-income senior citizens.

IPLA (Indiana Professional Licensing Agency)-Provides administrative support services to Indiana's professional licensing boards and commissions. Also, provides a process for licensing regulated professionals in Indiana.

IPN (Indiana Perinatal Network)-Alliance of individuals and organizations that serves to promote and protect the health and safety of mothers, babies, and families through consensus building, education, and collaborative partnerships among public and private organizations.

IRS (identical, related, or similar drugs)-In relation to LTE drugs.

ISBOH (Indiana State Board of Health)-Currently known as the Indiana State Department of Health.

ISDH (Indiana State Department of Health)-The State agency responsible for promotion of health, providing guidance on public health issues, ensuring the quality of health facilities and programs, and the administration of certain health programs. The Bureau of Family Health Services is the bureau within the ISDH organization charged with the administration of the Children's Special Health Care Services Division (CSHCS) as well as The Maternal and Child Health Division (MCH) and the Division of Women, Infants and Children (WIC). This agency is also responsible for surveying and certifying hospitals, long-term care facilities, home health agencies, FQHCs, and ICFs/MR. ISDH also maintains the database, CDMS - Chronic Disease Management System for the Indiana Chronic Disease Management Program.

Formerly known as Indiana State Board of Health (ISBOH).

Issue Management coordinator-The person responsible for ensuring that an owner is assigned to all issues based on the business most impacted, monitoring issues through completed and overdue reporting, assigning root cause category and closing issues.

itemization of charges-A breakdown of services rendered that allows each service to be coded.

ITF (integrated test facility)-A copy of the production version of IndianaAIM used for testing any maintenance and modifications before implementing changes in the production system.

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J400D-American Dental Association Claim Form effective April 15, 2007. Also referred to as ADA 2006. A common format for reporting dental services to a patient's dental benefit plan.

Jackson System (JS); Jackson System Development (JSD); Jackson System Programming (JSP)-JSD is distributed by a number of companies in Europe. JSD covers requirement analysis to maintenance. JSD proceeds by composition rather than by decomposition of processes. JSD includes the time dimension in the model of the enterprise; the dynamics are described first. JSD is mainly used for developing real-time systems.

JCAHO (Joint Commission on Accreditation of Healthcare Organizations)-The Joint Commission evaluates and accredits more than 15,000 healthcare organizations and programs in the United States. An independent, not-for-profit organization, the Joint Commission is the nation's predominant standards-setting and accrediting body in healthcare. Since 1951, the Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by healthcare organizations. The Joint Commission's comprehensive accreditation process evaluates an organization's compliance with these standards and other accreditation requirements.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-The Joint Commission evaluates and accredits more than 15,000 healthcare organizations and programs in the United States. An independent, not-for-profit organization, the Joint Commission is the nation's predominant standards-setting and accrediting body in healthcare. Since 1951, the Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by healthcare organizations. The Joint Commission's comprehensive accreditation process evaluates an organization's compliance with these standards and other accreditation requirements.

JS (Jackson System)-JSD is distributed by a number of companies in Europe. JSD covers requirement analysis to maintenance. JSD proceeds by composition rather than by decomposition of processes. JSD includes the time dimension in the model of the enterprise; the dynamics are described first. JSD is mainly used for developing real-time systems.

Also known as Jackson System Development and Jackson System Programming.

JSD (Jackson System Development)-JSD is distributed by a number of companies in Europe. JSD covers requirement analysis to maintenance. JSD proceeds by composition rather than by decomposition of processes. JSD includes the time dimension in the model of the enterprise; the dynamics are described first. JSD is mainly used for developing real-time systems.

Also known as Jackson System and Jackson System Programming.

JSP (Jackson System Programming)-JSD is distributed by a number of companies in Europe. JSD covers requirement analysis to maintenance. JSD proceeds by composition rather than by decomposition of processes. JSD includes the time dimension in the model of the enterprise; the dynamics are described first. JSD is mainly used for developing real-time systems.

Also known as Jackson System and Jackson System Development.

Julian date-A method of identifying days of the year by assigning numbers from 1 to 365 (or 366 on leap years) instead of by month, week, and day. For example, January 10 has a Julian date of 10 and December 31 has a Julian date of 365. This date format is easier and quicker for computer processing.

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K (kilobyte)-One thousand bytes. To a computer, it is actually 1,024. So, 16 kb, or 16K, is actually 16,384 bytes; 64K is 65,536 bytes, and so forth.

Kaizen-Japanese term that means continuous improvement, taken from words "Kai," which means continuous, and "Zen," which means improvement.

Kaizen event-A Japanese term for any action whose output is intended to be an improvement to an existing process. See Kaizen.

kb (kilobyte)-One thousand bytes. To a computer, it is actually 1,024. So, 16 kb, or 16K, is actually 16,384 bytes; 64K is 65,536 bytes, and so forth.

key field-Specific fields on the MDS that CMS has designated for the State to permit data entry errors to be corrected by way of a special request form.

Kilobyte (K or kb)-One thousand bytes. To a computer, it is actually 1,024. So, 16 kb, or 16K, is actually 16,384 bytes; 64K is 65,536 bytes, and so forth.

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labeler-Used with the meaning set forth in Section 1927(k)(5) of the Social Security Act except, for purposes of the drug rebate program, it shall also mean the entity holding legal title to or possession of the NDC number for the covered outpatient drug.

LBMS (Learmonth & Burchett Management System)-Company based in London that created the case tool currently used with IndianaAIM.

LCD (local coverage determination)-A decision by a MAC whether to cover a particular service on an MAC-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary).

Replaced LMRP 12/7/03.

Learmonth & Burchett Management System (LBMS)-Company based in London that created the case tool currently used with IndianaAIM.

Legacy Provider Identifier (LPI)-A provider's existing provider number or identification number assigned internally by a company such as IHCP, Medicare, or a private health insurance plan used to identify a provider.

Examples of LPIs include:

Online Survey Certification and Reporting (OSCAR) system numbers
National Supplier Clearinghouse (NSC) numbers
Provider Identification Numbers (PINs)
Unique Physician Identification Numbers (UPINs) used by Medicare
Medicaid Provider Number or Legacy Provider ID
IHCP Provider ID
They do not include taxpayer identifier numbers (TINs) such as:
Employer Identification Numbers (EINs)
Social Security Numbers (SSNs)

legend drug-Drugs that require a doctor's prescription. Identified by a Drug Class (CL) = "F."

length of stay (LOS)-A designation, generally correlated to the patient's diagnosis, that refers to the number of days that a patient is confined to an inpatient facility.

Level I-Indiana PASRR screening program to screen for depression. This must be done on every resident on admission.

Level II-Evaluation by a mental health professional for residents who exhibit signs and symptoms of a major mental illness and/or are receiving treatment, such as medication for a major mental illness.

Level II Referrals-Residents identified by the auditors during their review that would possibly benefit by having a Level II screening performed.

Level of Care (LOC)-Medical LOC review determinations are rendered by OMPP staff for purposes of determining nursing home reimbursement.

liaison-Fiscal agent staff members who are located in the area FSSA offices and assist with consumer enrollment, education, and issues.

licensed practical nurse (LPN)-A person who applies to the board for a license to practice as a licensed practical nurse must satisfy the requirements IC 25-23-1-12.

lien-A legal document filed with the court that is an official claim or demand for payment against a liable third party for medical bills paid by the IHCP for an illness or injury suffered by an IHCP member due to the negligence or act of another person.

lifetime reserve days-A nonrenewable 60-day period of additional hospital days awarded to Medicare beneficiaries.

Limited Liability Partnership (LLP)-A form of business organization combining elements of partnerships and corporations. In an LLP, all partners have a form of limited liability, similar to that of the shareholders of a corporation. However, the partners have the right to manage the business directly, and a different level of tax liability than in a corporation.

line item-Information on a claim that denotes a specific procedure or category of services, and the total charge billed for the procedures. Also used to describe lines within a screen segment; for example, those listed to describe periods of eligibility. Also called a line item or detail line.

Living Arrangement Code-A window on the MMIS that indicates the current living arrangement for a beneficiary.

LLP (Limited Liability Partnership)-A form of business organization combining elements of partnerships and corporations. In an LLP, all partners have a form of limited liability, similar to that of the shareholders of a corporation. However, the partners have the right to manage the business directly, and a different level of tax liability than in a corporation.

LOC (Level of Care)-Medical LOC review determinations are rendered by OMPP staff for purposes of determining nursing home reimbursement.

local codes-A generic term for code values that are defined for a state or other political subdivision, or for a specific payer. This term is most commonly used to describe HCPCS Level III Codes, but also applies to state-assigned Institutional Revenue Codes, Condition Codes, Occurrence Codes, Value Codes, and so forth.

Local County Office of Family Resources (OFR)-Formerly CDFC, now CDFR. County offices of FSSA servicing families and children through Temporary Assistance for Needy Families (TANF), food stamps, housing, child care, foster care, adoption, energy assistance, homeless services, and job programs. Local offices are located in each of Indiana's 92 counties. Caseworkers enroll members in the IHCP.

local coverage determination (LCD)-A decision by a MAC whether to cover a particular service on an MAC-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary).

Replaced LMRP 12/7/03.

Local Offices of Family Resources (OFR)-County offices of FSSA servicing families and children through Temporary Assistance for Needy Families (TANF), food stamps, housing, child care, foster care, adoption, energy assistance, homeless services, and job programs. Local offices are located in each of Indiana's 92 counties. Caseworkers enroll members in the IHCP. Formerly CDFC, now CDFR.

location-Location of the claim in the processing cycle such as paid, suspended, or denied.

lock-in-Administrative restriction of a member to particular providers for a specified time period. Providers that the member may see are considered "locked in" because other providers cannot be reimbursed for services performed for that member.

Restriction of a recipient to particular providers, determined as necessary by the State.

The punitive restriction of a Medicaid beneficiary to a particular provider for a period of time as determined by the State.

Restriction of a recipient to particular providers as determined by the State.

lock-out-Restriction of providers, for a time period, from participating in a portion or all of the IHCP due to exceeding standards defined by the department.

A term used when a provider or beneficiary has requested that a combination of their provider and beneficiary ID numbers not be made for managed care assignment purposes.

Logical Observation Identifiers, Names, and Codes (LOINC^®)-A clinical terminology important for laboratory test orders and results, produced by the Regenstrief Institute.

LOINC is one of a suite of designated standards for use in U.S. Government systems for the electronic exchange of clinical health information. LOINC is likely to become a HIPAA standard for some segments of the Claims Attachment transaction. In 1999, it was identified by the HL7 Standards Development Organization as a preferred code set for laboratory test names in transactions between healthcare facilities, laboratories, laboratory testing devices, and public health authorities.

LOINC^® (Logical Observation Identifiers, Names, and Codes)-A clinical terminology important for laboratory test orders and results, produced by the Regenstrief Institute.

LOINC is one of a suite of designated standards for use in U.S. Government systems for the electronic exchange of clinical health information. LOINC is likely to become a HIPAA standard for some segments of the Claims Attachment transaction. In 1999, it was identified by the HL7 Standards Development Organization as a preferred code set for laboratory test names in transactions between healthcare LTC Program. facilities, laboratories, laboratory testing devices, and public health authorities.

Long Term Care (LTC) Program-A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care.

long-term care (LTC)-Used to describe facilities that supply long-term residential care to members.

Beneficiary care that includes room, board, and all routine services and supplies. The LTC program includes the SNF, ICF and ICF/MR services.

LOS (length of stay)-A designation, generally correlated to the patient's diagnosis, that refers to the number of days that a patient is confined to an inpatient facility.

lost call-A call is considered lost if the caller is connected to the system but hangs up before being connected with an agent or informational announcement.

Also known as an abandoned call.

LPI (Legacy Provider Identifier)-A provider's existing provider number or identification number assigned internally by a company such as IHCP, Medicare, or a private health insurance plan used to identify a provider.

Examples of LPIs include:

Online Survey Certification and Reporting (OSCAR) system numbers
National Supplier Clearinghouse (NSC) numbers
Provider Identification Numbers (PINs)
Unique Physician Identification Numbers (UPINs) used by Medicare
Medicaid Provider Number or Legacy Provider ID
IHCP Provider ID
They do not include taxpayer identifier numbers (TINs) such as:
Employer Identification Numbers (EINs)
Social Security Numbers (SSNs)

LPN (licensed practical nurse)-A person who applies to the board for a license to practice as a licensed practical nurse must satisfy the requirements IC 25-23-1-12.

LTC (Long Term Care Program) Program-A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care.

LTC (long-term care)-Used to describe facilities that supply long-term residential care to members.

Beneficiary care that includes room, board, and all routine services and supplies. The LTC program includes the SNF, ICF and ICF/MR services.

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M.E.D. Works (Medicaid for Employees with Disabilities)-A category of eligibility for Medicaid. It is intended for people who are disabled and work, and whose income and/or assets are more than the amounts allowed for Medicaid Disability (the standard Medicaid program). These workers use M.E.D. Works in lieu of spend-down (which is part of the Medicaid Disability program).

MAC (maximum allowable charge or maximum allowable cost)-Pertains to drugs as specified by the federal government.

MAC (Medicare administrative contractor)-MACs replace Medicare carriers and fiscal intermediaries beginning in 2005.

magnetic resonance imaging (MRI)-A noninvasive diagnostic technique that produces computerized images of internal body tissues and is based on nuclear magnetic resonance of atoms within the body induced by the application of radio waves.

Maint Level 1-Emergency: system no longer functions - Must be corrected within one business day.

Maint Level 2-Disabled - No Workaround: Business function or components of the business function do not work as required, and no workaround is available - Must be corrected within 10 business days.

Maint Level 3-Disabled - Workaround: Business function or components of the business function do not work as required, but a workaround that is acceptable to the State is available until the problem is resolved - Must be corrected within 25 business days.

Maint Level 4-Minor: Non-critical problems - Must be corrected within 40 business days.

Maint Level 5-Minimal: Cosmetic - Must be corrected with 50 business days.

Maint-1-Activities necessary to correct deficiencies (for example, incorrect pricing logic, incorrect logic for edits and audits, incorrect report calculations, and so forth) within IndianaAIM, including deficiencies found after implementation of modifications incorporated into IndianaAIM.

Maint-2-Activities necessary for the system to meet the performance requirements, detailed in the OMPP/HP RFP, including operations support.

Maint-3-Activities necessary to ensure that data, tables, programs, and documentation are current and that errors are found and corrected.

Maint-4-Data maintenance activities for updates to tables, including database support activities.

Maint-5-Changes to scripts or system parameters concerning the frequency, number, sorting, and media of reports.

Maint-6-Changes to disposition parameters concerning (reference file) for established edit or audit criteria.

Maintenance CO (Change Order)-Maintenance Change Order with five severity levels and six support categories as defined by the OMPP.

Maintenance Level-Refers to the five performance levels of maintenance activities.

Maintenance Support Categories-System maintenance support work is defined in six categories: Maint-1 through Maint-6.

managed care-System where the overall care of a patient is overseen by a single provider or organization. Many state Medicaid programs include managed care components as a method of ensuring quality in a cost-efficient manner.

Comprehensive healthcare integrating clinic/admin for cost-effective care (HMO). Managed Care includes capitated HMO, PCCM, and Fee-For-Service managed care.

managed care entity (MCE)-An individual or organization that participates in the managed care program, either by provision of managed care services or through program administration.

State-contracted vendors that provide the administration for the care management and managed care programs. The vendors include the care management organizations (CMOs) - ADVANTAGE Health Solutions and MDwise Care Select and the managed care organizations (MCOs) - Anthem, Managed Health Services (MHS) and MDwise.

Managed Care for Persons with Disabilities(MCPD)-One of three delivery systems in the Hoosier Healthwise managed care program. In MCPD, a managed care organization is reimbursed on a per capita basis per month to manage the member's healthcare. This delivery system serves people identified as disabled under the Indiana Medicaid definition.

managed care organization (MCO)-Lawful entities authorized to operate a prepaid health care delivery plan (as an HMO) on a capitated basis that arranges, administers and pays for the delivery of health care services to members as designated by the OMPP.

managed care organization enrollee or member-An IHCP or CHIP enrollee participating in Hoosier Healthwise and enrolled in one of the Hoosier Healthwise MCOs.

managed care PCCM (primary care case management)-Members in the PCCM delivery system are linked to a PMP that acts as a gatekeeper by providing and arranging for most of the members' medical care. The PMP receives an administrative fee per month for every member and is reimbursed on an FFS basis. The PCCM delivery system for children, low-income families, and pregnant women ceased to exist on December 31, 2005. Medicaid Select, a managed care program for the aged, blind and disabled, was considered PCCM and ceased to exist February 28, 2008.

Managed Care Programs-Programs that represent any of a variety of case management types of programs and plans that may operate on a fee-for-service or full or partial capitation basis.

managed care RBMC (risk-based managed care)-In a risk-based managed care delivery system, the OMPP pays contracted MCOs a capitated monthly premium for each IHCP enrollee in the MCO's network. The care of members enrolled in the MCO is managed by the MCO through its network of PMPs, specialists, and other providers of care, who contract directly with the MCO.

managed care representatives (MCR)-Fiscal agent employees primarily responsible for contracting with PCCMs.

Managed Care Unit (MCU)-The HP Managed Care Unit provides support services to the OMPP in the administration of the health plan programs.

Managed Health Services (MHS)-An MCO responsible for statewide coverage for Hoosier Healthwise participants.

Management and Administrative Reporting Subsystem (MAR, MARS)-A federally mandated comprehensive reporting module of IndianaAIM that includes data and reports as specified by federal requirements.

The MMIS subsystem that produces the management data required for financial, benefit, provider and beneficiary reporting.

mandated or required services-Services a state is required to offer to categorically needy clients under a state Medicaid plan. (Medically needy clients may be offered a more restrictive service package.) Mandated services include the following: hospital (IP/OP), lab/x-ray, NF care (21 and over), home healthcare, family planning, physician, nurse midwives, dental (medical/surgical), RHC, certain nurse practitioners, federally qualified health centers, renal dialysis services, HealthWatch EPSDT (under age 21), and medical transportation.

manual checks-Checks written outside the automated check writing cycle.

manual claim Claim for services submitted on a paper claim form rather than via electronic means; also referred to as paper and hard copy.

Claims processed outside the automated claims cycle.

manual pricing-This indicator applies to procedures that require individual and manual consideration.

The process by which an allowed amount is determined for a procedure which does not have a set rate on file. Encounter data do not suspend for manual pricing. The "billed amount" becomes the "allowed amount.

manual recoupments-Manual recoupments are nonclaim-specific recoupments (financial reimbursements). These accounts receivable are manually set up by the State of Indiana to recoup money from providers.

MAR, MARS (Management and Administrative Reporting Subsystem)-A federally mandated comprehensive reporting module of IndianaAIM that includes data and reports as specified by federal requirements.

The MMIS subsystem that produces the management data required for financial, benefit, provider and beneficiary reporting.

mass adjustments-The systematic adjustment of more than one claim at the same time for the same reason. Multiple adjustments entered at one time. Mass adjustments are requested online and they are particularly useful when it is necessary to reprocess hundreds or thousands of claims. Mass adjustment requests are submitted for a specific population of claims. In other words, claims that have something in common. They may be all of the drug claims processed after a certain date, they may be a subset of claims for a specific provider, or they may be all of the claims processed for a specific beneficiary. The criterion for claims selection is highly variable.

maternal and child health (MCH)-The Maternal & Child Health (MCH) Services Block Grant (Title V) works to provide health services to women, children and families.

Title V strives to improve the health of all women, infants, children, and adolescents. Federal funds are allocated to states and territories to support maternal and child health services. These Title V funds help shape and monitor health-related services for women, children, and youth by providing resources; delivering critical screening services; and supporting preventive, primary, and specialty care.

maximum allowable charge or maximum allowable cost (MAC)-Pertains to drugs as specified by the federal government.

MAXIMUS-Member enrollment broker organization..

MCE (managed care entity) An individual or organization that participates in the managed care program, either by provision of managed care services or through program administration.

mcg (microgram)-mcg is equal to 1/1000^th of a mg

MCH (Maternal and Child Health)-The Maternal & Child Health (MCH) Services Block Grant (Title V) works to provide health services to women, children and families.

MCO (managed care organization)-Lawful entities authorized to operate a prepaid health care delivery plan (as an HMO) on a capitated basis that arranges, administers and pays for the delivery of health care services to members as designated by the OMPP.

MCO denied claim-An MCO denied claim is indicated by a zero-paid amount, along with one or more of the MCO's denial adjustment reason codes.

MCO Identification Number-A nine-byte field used to identify the MCO submitting encounter data.

MCO Region Identifier-A one-byte field used to identify the region of the MCO submitting encounter data.

MCPD (Managed Care for Persons with Disabilities)-One of three delivery systems in the Hoosier Healthwise managed care program. In MCPD, a managed care organization is reimbursed on a per capita basis per month to manage the member's healthcare. This delivery system serves people identified as disabled under the Indiana Medicaid definition.

MCR (managed care representatives)-Fiscal agent employees primarily responsible for contracting with PCCMs.

MCU (Managed Care Unit)-The HP Managed Care Unit provides support services to the OMPP in the administration of the health plan programs.

MDwise-An MCO responsible for statewide coverage for Hoosier Healthwise participants.

MDwise - Care Select-State-contracted vendor that performs Care Select - care management organization (CMO) activities that include care management, prior authorization, restricted card, and management of the utilization of physical, behavioral, and transportation services for its membership. Use this version of the name when referring to the Care Select CMO prior authorization and restricted card vendor.

MDwise with AmeriChoice-State-contracted insurer for the Healthy Indiana Plan program.

Medicaid-A joint federal-state entitlement program that pays for medical care on behalf of certain groups of low-income persons. The program was enacted in 1965 under Title XIX of the Social Security Act.

The joint federal and state medical assistance program that is described in Title XIX of the Social Security Act, designed to provide health benefits assistance to medically needy young persons (less than 21 years of age) and to the aged (more than 65 years of age). A health insurance program for the poor which is jointly funded by the state and federal governments. Also, referred to as Title XIX of the Social Security Act. The Medicaid Program is administered by the states under the management of the Centers for Medicare and Medicaid (CMS).

Federal/State partnership of medical assistance for low income (title XIX, SS act) persons. There are 33 million people eligible. Includes ABD, low-income with children, low-income pregnant, and people with very high medical bills. In order to receive medical assistance a client must qualify into one of (6) categories: age 65, Blind, disabled, families with dependent children (TANF), pregnant, incapacitated (= categorically needy).

For Indiana, Medicaid is IN XIX.

Medicaid certification-The determination of a member's entitlement to Medicaid benefits and notification of that eligibility to the agency responsible for Medicaid claims processing.

Medicaid covered service-A service provided or authorized by an IHCP provider for an IHCP enrollee for which payment is available under the IHCP as set forth in 405 IAC 5. A list of covered services is referenced in IC 12-15-5-1..

Medicaid Financial Report-State Form 7748, used for cost reporting.

Medicaid fiscal agent-Contractor that provides the full range of services supporting the business functions included in the core and non-core service packages. For Indiana Medicaid, the fiscal agent is HP.

Medicaid for Employees with Disabilities (M.E.D. Works)-A category of eligibility for Medicaid. It is intended for people who are disabled and work, and whose income and/or assets are more than the amounts allowed for Medicaid Disability (the standard Medicaid program). These workers use M.E.D. Works in lieu of spend-down (which is part of the Medicaid Disability program).

Medicaid Fraud Control Unit (MFCU) or Indiana Medicaid Fraud Control Unit (IMFCU)-Investigative branch of the Attorney General's Office. IMFCU conducts investigations into Medicaid provider fraud, misuse of Medicaid funds, and patient abuse or neglect in Medicaid facilities. The unit presents the case to the state or federal prosecutors for appropriate action.

Medicaid in Process-A resident who has an IHCP number and all information has been sent to the State, but Form 450B is not back with an effective date and signature present.

Medicaid Information Technology Architecture (MITA)-CMS initiative which will eventually replace MMIS. Began in 2004 and expected to last a decade or more.

Medicaid Management Information System (MMIS)-Indiana's current MMIS is referred to as IndianaAIM.

The IHCP payment and information system of the Indiana Family and Social Services Administration; also known as IndianaAIM.

Medicaid or Medical Assistance Program-Medicaid is a federal- and state-mandated medical assistance program administered by the State to provide reasonable and necessary medical care for persons meeting medical and financial eligibility requirements pursuant to federal law, 42 U.S.C. 1396 and state law, IC 12-15. The Medicaid program in Indiana is known as IHCP.

Medicaid Recipient/Indiana Health Coverage Programs Enrollee-An IHCP enrollee in one of these aid categories: Aged; Blind and Disabled; Temporary Assistance for Needy Families; Pregnancy Medicaid; or Children's Medicaid.

Medicaid Select-A program that administered managed care for the aged, blind, and disabled Medicaid population. Medicaid Select ceased to exist as of February 28, 2008, and was replaced by the Care Select program.

Medicaid Select Administrative Fee Listing-Monthly case management fees of $4 are paid for every member actively assigned to a Medicaid Select PMP. Fee Listings are mailed to the PMP each month and list the members for whom the PMP is receiving administrative payment.

Medicaid Select Certification Code Letter-Certification codes are assigned to each Hoosier Healthwise PMP enrolled in the Medicaid Select network. PMPs use the certification code to authorize specialty care or other medical services/equipment for members assigned to their panel. The Medicaid Select Certification Code Letter is generated and mailed quarterly to each actively enrolled Medicaid Select PMP. The letter informs the PMP of their confidential certification code for the current and previous quarters.

Medicaid Select Member Enrollment Roster-See Enrollment Roster.

Medicaid Statistical Information System (MSIS)-Reporting required by CMS in standard formats. MSIS reports are required by each state and combined by CMS.

Medicaid Waiver Unit (MWU)-The IDDARS unit that manages the HCBS Waiver Programs.

Medical Necessity-A documented decision by a medical practitioner that a therapy, treatment, drug, item, or service prescribed or provided is essential to treat or diagnose a specific physical or psychiatric condition.

Medically necessary services covered by the IHCP are specified in 405 IAC 5.

medical policy-Portion of the claim processing system whereby claim information is compared to standards and policies set by the state for the IHCP.

medical policy contractor-Successful bidder on Service Package #2: Medical Policy and Review Services.

Medical Review-Analysis of Medicaid claims to ensure that the service was necessary and appropriate.

Medical Review Team (MRT)-A unit that makes decisions regarding disability determination.

medical supplies-Supplies, appliances, and equipment.

medically necessary-Medically necessary services covered by the IHCP are specified in 405 IAC 5.

medically needy-Individuals whose income and resources equal or exceed the levels for assistance established under a state or federal plan, but are insufficient to meet their costs of health and medical services.

Medicare-The federal medical assistance program described in Title XVIII of the Social Security Act for people over the age of 65, for persons eligible for Social Security disability payments, and for certain workers or their dependents who require kidney dialysis or transplantation.

Medicare Administrative Contractor (MAC)-MACs replace Medicare carriers and fiscal intermediaries beginning in 2005. For more information, see Part A/Part B Medicare Administrative Contractor on the CMS Web site..

Medicare crossover-Process allowing for payment of Medicare deductibles and coinsurance by the Medicaid program.

Medicare deductibles and coinsurance-All charges classified as deductibles or coinsurance under Medicare Part A or Part B for services authorized by Medicare Part A or Part B.

Medicare Part A, Part A-The part of Medicare that covers hospice care, home healthcare, skilled NFs, and inpatient hospital stays. Part A helps pay for medically necessary inpatient hospital care; and after a hospital stay, for inpatient care in a skilled NF; for home care by a home health agency; or hospice care by a licensed and certified hospice agency.

Part A of Title XVIII of the Social Security amendments of 1965 that provided benefits principally for hospital and hospital-related services. The formal designation is "Hospital Insurance Benefits for the Aged."

Medicare Part B, Part B-The part of Medicare that helps pay for doctors, outpatient hospital care, and other medical services not requiring hospitalization. Part B helps pay for medically necessary physician services, outpatient hospital services, outpatient physical therapy, and speech pathology services, and a number of other medical services and supplies that are not covered by the hospital insurance. Part B pays for certain inpatient services if the beneficiary does not have Part A.

Part B of Title XVIII of the Social Security amendments of 1965 that provided benefits principally for physician's services. The formal designation is "Supplementary Medical Insurance Benefits for the Aged."

Medicare Part D, Part D, Medicare D-The Medicare Prescription Drug, Improvement, and Modernization Act passed December 8, 2003, and the Medicare Prescription Drug Improvement and Modernization Act of 2003, also known as the Medical Reform Act, established a voluntary drug benefit for Medicare beneficiaries and created a new Medicare Part D.

The program provides elderly and disabled people already on Medicare access to drug coverage as of January 2006.

Medicare Part D PDPs are government-sponsored insurance policies (issued by commercial insurance companies) designed to help defray the costs of prescription drugs. Anyone with Medicare Part A or Part B can purchase a prescription drug benefit plan through private insurance companies beginning on November 15, 2005.

Medicare Remittance Notice (MRN)-A form provided by IndianaAIM and sent to providers. The MRN details the payment or denial of claims submitted by providers for services provided to members.

Medicare secondary payer (MSP)-Term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about coordination of benefits when assigning responsibility for first and second payment.)

The term is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the gaps in Medicare's coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or coinsurance amounts or other limits under the Medicare program.

MEDIGAP-In relation to Medicare, this private health insurance pays most of the healthcare service charges not covered by Parts A or B of Medicare. These policies, which must meet federally imposed standards, are offered by many commercial health insurance companies.

Member Enrollment Roster-Reports sent to MCO and Care Select PMPs, twice monthly, for their information of members assigned to their panel.

member identification number / recipient identification (RID) number-The unique code assigned to an individual who is eligible for medical assistance programs.

member or enrollee-An IHCP recipient who is enrolled in any of the state's health coverage programs.

An individual who has been determined to be eligible for payment to, or on behalf of, part or all of the cost of medical or remedial services pursuant to IC 12-1-7-14.9 (a) and/or IC 16-6.5-2 (for CSHCS members) or the Children Health Insurance Program (CHIP).

member relations-The activity within the single state agency that handles all relationships between the IHCP and individual members.

member restriction-A limitation or review status placed on a member that limits or controls access to the IHCP to a greater extent than for other non-restricted members.

Member Welcome Letter-The welcome letter serves as the member's notification of enrollment in the managed care and care management programs. The letter confirms the member's PMP selection and service location address assignment and provides a contact number for any questions regarding the member assignment.

Memoranda of Collaboration (MOC) or Memorandum of Collaboration (MOC)-A Hoosier Healthwise document that provides a formal description of the terms of collaboration between the PMP and the PHCSP, and serves as a tool for delineating responsibilities for referrals on a continuous basis. MOCs must be signed by both parties and are subject to OMPP approval.

mental disease-Any condition classified as a neurosis, psychoneurosis, psychopathy, psychosis, or personality disorder.

Mental Health Quality Advisory Committee (MHQAC)-An advisory committee set up by state legislation to advise the Indiana Medicaid Drug Utilization Review Board on therapeutic and cost effective mental health therapies.

mental illness (MI)-A single severe mental disorder, excluding mental retardation, or a combination of severe mental disorders as defined in the most current edition of the American Psychiatric Association's DSM.

mental retardation and developmentally disabled (MR/DD)-An HCBS classification for beneficiaries who are mentally retarded or developmentally disabled.

mental retardation/mentally retarded-Significantly subaverage intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.

Significantly sub-average intellectual functioning, evidenced by an IQ rating of 70 or below on any standardized measure of intelligence, concurrently existing deficits in adaptive behavior as listed in the Other Development Disability definition.

MFCU (Medicaid Fraud Control Unit)-Investigative branch of the Attorney General's Office. MFCU conducts investigations into Medicaid provider fraud, misuse of Medicaid funds, and patient abuse or neglect in Medicaid facilities. The unit presents the case to the state or federal prosecutors for appropriate action. See also IMFCU.

mg (milligram)-mg is equal to 1/1000^th of a gram

MHQAC (Mental Health Quality Advisory Committee)-An advisory committee set up by state legislation to advise the Indiana Medicaid Drug Utilization Review Board on therapeutic and cost effective mental health therapies.

MHS (Managed Health Services)-An MCO responsible for statewide coverage for Hoosier Healthwise participants.

MI (mental illness)-A single severe mental disorder, excluding mental retardation, or a combination of severe mental disorders as defined in the most current edition of the American Psychiatric Association's DSM.

MI (myocardial infarction)-The temporary reduction in or blockage of blood in the coronary vasculature resulting in various arrhythmias or asystole.

microfiche-Miniature copies of the RAs that can store approximately 200 pages of information on a plastic sheet about the size of an index card.

microfilm-Miniature copies of all claims received by Medicaid stored on film for permanent recordkeeping and referral.

microgram (mcg)-mcg is equal to 1/1000^th of a mg

milligram (mg)-mg is eqyal to 1/1000^th of a gram

milliliter (ml)-ml is eual to 1/1000^th of a liter. Also known as "cc"

Minimum Necessary Required-Limiting the use of disclosure of PHI to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request. In other words, you only have access to the minimum amount of PHI necessary to perform your defined work function.

misutilization-Any usage of the IHCP by any of its providers or members not in conformance with both state and federal regulations, including both abuse and defects in level and quality of care.

MITA (Medicaid Information Technology Architecture)-CMS initiative which will eventually replace MMIS. Began in 2004 and expected to last a decade or more.

mix-Refers to an additive measure of a combination of different individual profiles seen in a specific setting or facility.

ml (milliliter)-ml is eual to 1/1000^th of a liter. Also known as "cc"

MMDDYY or MMDDCCYY-Format for a date to be reflected as month, day, and year, such as 081508 for August 15, 2008. Format for a date to be reflected as month, day, century, and year, such as 08152008 for August 15, 2008.

MMIS (Medicaid Management Information System)-Indiana's current MMIS is referred to as IndianaAIM.

The IHCP payment and information system of the Indiana Family and Social Services Administration; also known as IndianaAIM.

MOC (Memoranda of Collaboration or Memorandum of Collaboration)-A Hoosier Healthwise document that provides a formal description of the terms of collaboration between the PMP and the PHCSP, and serves as a tool for delineating responsibilities for referrals on a continuous basis. MOCs must be signed by both parties and are subject to OMPP approval.

modifier-Provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. An example would be the service or procedure had both a professional and a technical component.

Module-A group of data processing or manual processes that work in conjunction with each other to accomplish a specific function.

Molina-An MCO responsible for statewide coverage for Hoosier Healthwise participants prior to January 1, 2007.

Money grant members-Money grant members are members who receive all, or any portion, of their monthly income from any of the sources below:

Social Security Income (SSI), which includes certain individuals no longer eligible for SSI cash assistance due to increased resources, but who retain their SSI member status under the provisions of Section 1619 of the Social Security Act.

Temporary Assistance for Needy Families (TANF).

Room and Board Assistance (RBA).

monthly obligation-Term used to refer to spend-down.

MR (mental retardation/mentally retarded)-Significantly subaverage intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.

MR/DD (mental retardation and developmentally disabled)-An HCBS classification for beneficiaries who are mentally retarded or developmentally disabled.

MRI (magnetic resonance imaging)-A noninvasive diagnostic technique that produces computerized images of internal body tissues and is based on nuclear magnetic resonance of atoms within the body induced by the application of radio waves.

MRN (Medicare Remittance Notice)-A form provided by IndianaAIM and sent to providers. The MRN details the payment or denial of claims submitted by providers for services provided to members.

MRT (Medical Review Team)-A unit that makes decisions regarding disability determination.

MSIS (Medicaid Statistical Information System)-Reporting required by CMS in standard formats. MSIS reports are required by each state and combined by CMS.

MSP (Medicare secondary payer)-Term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about coordination of benefits when assigning responsibility for first and second payment.)

MVS OS (Access Control Facility/Multiple Virtual Storage)-A Security Extension to the IBM Multiple Virtual Storage Operating System.

MWU (Medicaid Waiver Unit)-The IDDARS unit that manages the HCBS Waiver Programs.

Myers and Stauffer LC-Myers and Stauffer LC is a certified public accounting firm that provides accounting, consulting, data management and analysis services to government-sponsored healthcare programs. The firm is a contractor for the Indiana Office of Medicaid Policy and Planning, the agency that administers the Medicaid Program for the state of Indiana. Note: Use "and" rather than ampersand between Myers and Stauffer.

myocardial infarction (MI)-The temporary reduction in or blockage of blood in the coronary vasculature resulting in various arrhythmias or asystole.

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National Committee For Quality Assurance (NCQA)-Not a government entity. NCQA is an independent non-profit organization that measures performance of managed care. Some states use the NCQA's Health Plan Employer Data and Information Set (HEDIS) to measure the performance of managed care plans serving Medicaid beneficiaries.

National Committee on Vital and Health Statistics (NCVHS)-The NCVHS serves as the statutory [42 U.S.C. 242k(k)]public advisory body to the Secretary of Health and Human Services in the area of health data and statistics. In that capacity, the committee provides advice and assistance to the department and serves as a forum for interaction with interested private sector groups on a variety of key health data issues.

National Council for Prescription Drug Programs (NCPDP)-An ANSI-accredited group that maintains a number of standard formats for use by the retail pharmacy industry, some of which are included in the HIPAA mandates.

An ANSI-accredited council developed to review and define national standards for the billing of prescription drug services for reimbursement by private insurance as well as state and federal agencies. Some of the standard formats are included in the HIPAA mandates.

A not-for-profit ANSI-Accredited Standards Development Organization.

A prescribed drug claim that came through the POS system.

Provides standards for data interchange and standards for processing pharmacy services in the healthcare industry. The NCPDP Telecommunications Standard defines the record layout for interactive prescription drug claim transactions between providers and adjudicators.

National Drug Code (NDC)-A generally accepted system for the identification of prescription and non-prescription drugs available in the United States. NDC includes all subsequent editions, revisions, additions, and periodic updates.

Provider of communication software/hardware for pharmacies. (See ENVOY.) or

Each listed drug product listed is assigned a unique 10-digit, 3-segment number. This number, known as the NDC, identifies the labeler, product, and trade package size. The first segment, the labeler code, is assigned by the FDA. A labeler is any firm that manufactures (including repackers or relabelers), or distributes (under its own name) the drug. The second segment, the product code, identifies a specific strength, dosage form, and formulation for a particular firm. The third segment, the package code, identifies package sizes and types. Both the product and package codes are assigned by the firm. The NDC will be in one of the following configurations: 4-4-2, 5-3-2, or 5-4-1.

An asterisk may appear in either a product code or a package code. It simply acts as a place holder and indicates the configuration of the NDC. Since the NDC is limited to 10 digits, a firm with a 5-digit labeler code must choose between a 3-digit product code and 2-digit package code, or a 4-digit product code and 1-digit package code.

Thus, you have either a 5-4-1 or a 5-3-2 configuration for the three segments of the NDC. Because of a conflict with the HIPAA standard of an 11-digit NDC, many programs will pad the product code or package code segments of the NDC with a leading zero instead of the asterisk.

Since a zero can be a valid digit in the NDC, this can lead to confusion when trying to reconstitute the NDC back to its FDA standard. Example: 12345-0678-09 (11 digits) could be 12345-678-09 or 12345-0678-9 depending on the firm's configuration. By storing the segments as character data and using the * as place holders, we eliminate the confusion. In the example, FDA stores the segments as 12345-*678-09 for a 5-3-2 configuration or 12345-0678-*9 for a 5-4-1 configuration.

National Drug Data File (NDDF)-NDDF Plus combines drug descriptive and pricing information with an extensive array of clinical decision-support modules. It encompasses medications approved by the FDA, plus information on commonly-used over-the-counter and alternative therapy agents, such as herbals, nutraceuticals and dietary supplements.

National Electronic Claims Software or National Electronic Claims Submission (NECS)-The proprietary software developed by HP. NECS is installed on a provider's PCs and used to submit claims electronically. The software allows providers access to online, real-time eligibility information.

National Heritage Insurance Company, Corp. (NHIC, Corp.)-An HP insurance subsidiary

National Hospice and Palliative Care Organization, Inc. (NHPCO)-Founded in 1978, the National Hospice and Palliative Care Organization is the oldest and largest nonprofit public benefit organization devoted exclusively to hospice care. NHPCO is dedicated to promoting and maintaining quality care for terminally ill persons and their families, and to making hospice an integral part of the U.S. healthcare system.

National Institute of Standards and Technology (NIST)-Founded in 1901, NIST is a nonregulatory federal agency within the U.S. Department of Commerce's Technology Administration. NIST's mission is to develop and promote measurement, standards, and technology to enhance productivity, facilitate trade, and improve the quality of life.

National Medicaid EDI Healthcare Workgroup (NMEH)-A consortium of State Medicaid agencies and Fiscal Intermediaries who meet biweekly via teleconference to discuss Medicaid-specific HIPAA implementation issues. NMEH has established sub-workgroups that are involved in the analysis of the major Transaction Sets and related functional healthcare code-sets. CMS representatives also participate in the teleconferences and provide guidance and interpretation of Final and Proposed HIPAA Rules.

National Payor ID-A system for uniquely identifying all organizations that pay for healthcare services. Also known as Health Plan ID, or Plan ID.

National Plan and Provider Enumeration System (NPPES)-CMS-funded entity that assigns the 10-digit NPI. The NPPES processes the applications and updates, ensures the uniqueness of the healthcare provider and generates the NPIs. See FOX Systems Inc.

National Provider Identifier (NPI)-The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for health care providers. The NPI Final Rule issued January 23, 2004 adopted the NPI as this standard.

The NPI is a 10-digit, intelligence free numeric identifier (10 digit number). Intelligence free means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization.

The NPI will replace health care provider identifiers in use today in HIPAA standard transactions. Those numbers include Medicare legacy IDs (UPIN, OSCAR, PIN, and National Supplier Clearinghouse or NSC).

The provider's NPI will not change and will remain with the provider regardless of job or location changes.

National Provider System (NPS)-The administrative system for supporting a national provider registry.

An application system through which users have the capability to assign NPIs to providers and to access/update provider identification data.

A voluntary federal and state joint venture to support CMS' Medicare Transaction System and to simplify program operations and provider transactions across programs. It will replace the existing Medicare Physician Identification and Eligibility System (MPIES) that currently issues the Medicare Unique Physician Identification Number (UPIN). Subsequently, new physicians would obtain a National Provider Identifier (NPI) rather than a UPIN number.

National Standard Format (NSF)-Was designed to standardize and increase the submission of electronic claims and coordination of benefits exchange. The NSF is used to electronically submit healthcare claims and encounter information from providers of healthcare services to payers. It is also used to exchange healthcare claims and payment information between payers with different payment responsibility.

National Uniform Billing Committee (NUBC)-The principal goal of the NUBC is to develop, promote, and maintain a uniform standard data set and format(s), which can be used by the institutional healthcare community to transmit related charge and claim information to all third-party payers. With the data set operational, one of the NUBC's major roles is to maintain the integrity of the UB-04 data set. In addition, the NUBC serves as the forum for discussions that lead to mutually agreed data elements for the claim as well as the data elements for other claim-related transactions.

The NUBC parallels the National Uniform Claim Committee (NUCC) for the non-institutional healthcare community.

National Uniform Claim Committee (NUCC)-An organization, chaired and hosted by the American Medical Association, that maintains the CMS-1500 claim form and a set of data element specifications for professional claims submission via the CMS-1500 claim form, the Professional EMC NSF, and the X12 837. The NUCC also maintains the Provider Taxonomy Codes and has a formal consultative role under HIPAA for all transactions affecting non-dental non-institutional professional healthcare services.

NCPDP (National Council for Prescription Drug Programs)-An ANSI-accredited group that maintains a number of standard formats for use by the retail pharmacy industry, some of which are included in the HIPAA mandates.

A not-for-profit ANSI-Accredited Standards Development Organization.

A prescribed drug claim that came through the POS system.

NCQA (National Committee for Quality Assurance)-Not a government entity. NCQA is an independent non-profit organization that measures performance of managed care. Some states use the NCQA's Health Plan Employer Data and Information Set (HEDIS) to measure the performance of managed care plans serving Medicaid beneficiaries.

NCVHS (National Committee on Vital and Health Statistics)-The NCVHS serves as the statutory [42 U.S.C. 242k(k)]public advisory body to the Secretary of Health and Human Services in the area of health data and statistics. In that capacity, the committee provides advice and assistance to the department and serves as a forum for interaction with interested private sector groups on a variety of key health data issues.

NDC (National Drug Code)-A generally accepted system for the identification of prescription and non-prescription drugs available in the United States. NDC includes all subsequent editions, revisions, additions, and periodic updates.

Provider of communication software/hardware for pharmacies. (See ENVOY.) or

NDDF (National Drug Data File)-NDDF Plus combines drug descriptive and pricing information with an extensive array of clinical decision-support modules. It encompasses medications approved by the FDA, plus information on commonly-used over-the-counter and alternative therapy agents, such as herbals, nutraceuticals and dietary supplements.

NECS (National Electronic Claims Submission) or (National Electronic Claims Software)-The proprietary software developed by HP. NECS is installed on a provider's PCs and used to submit claims electronically. The software allows providers access to online, real-time eligibility information.

NEMT (Non-Emergency Medical Transportation)-Non-commercial medical transportation provided to beneficiaries in private vehicles, including their own.

Network-Network refers to MCO-specific networks such as St. Francis and Clarian.

Network Model HMO-An HMO type in which the HMO contracts with more than one physician group, and may contract with single- and multi-specialty groups. The physician works out of his or her own office. The physician may share in utilization savings but does not necessarily provide care exclusively for HMO members.

new day claim-Any claim, with or without attachments, received for payment consideration on that current business day. A claim is only considered "new day" on the initial date of receipt. Once the current day has passed, all unkeyed new day claims become part of the shelf inventory, which consists of all claims waiting to be processed.

new drug-A covered outpatient drug approved as a new drug under section 201(p) of the Federal Food, Drug, and Cosmetic Act.

new drug coverage-Begins with the date of FDA approval of the NDA, PLA, ELA OR ADA, for a period of six months from that date, with the exception of drugs not under the rebate agreement or classes of drugs states elect to exclude.

newsletter-Publication produced for IHCP providers on a monthly basis.

NF (nursing facility)-Facility licensed by and approved by the State in which eligible individuals receive nursing care and appropriate rehabilitative and restorative services under the Title XIX (Medicaid) Long Term Care Program.

An institution or a distinct part of an institution which is primarily engaged in providing to residents: nursing care and related services, rehabilitation services or health related care, and services (above the level of room and board) which can be made available only in an institutional facility. The facility must have in effect a transfer agreement with one or more hospitals and must meet Medicaid participation requirements.

Any place or facility operating for not less than twenty-four (24) hours in any day and caring for six or more individuals not related within the third degree of relationship to the administrator or owner by blood or marriage and who by reason of aging, illness, disease or physical or mental infirmity are unable to sufficiently or properly care for themselves, and for whom reception, accommodation, board and skilled nursing care and treatment is provided, and which place or facility is staffed to provide 24-hour-a-day, licensed, nursing personnel plus additional staff, and is maintained and equipped primarily for the accommodation of individuals who are not acutely ill and are not in need of hospital care but who require skilled nursing care.

Also referred to as ECF, NH, and LTC.

NF (nursing facility) waiver-A waiver of the Medicaid's state plan granted under Section 1915c of the Social Security Act that allows Indiana to provide community-based services to adults as an alternative to NF care.

NF/MH (Nursing Facility For Mental Health)-Any nursing facility that provides room, board, and all routine services and supplies for beneficiaries with mental health needs.

NFSN (Nursing Facility For Skilled Nursing)-Any nursing facility that provides room, board, and all routine services and supplies for beneficiaries with skilled nursing needs.

NH (nursing home)-Also referred to as ECF, NF, and LTC.

NHIC Corp. (National Heritage Insurance Company, Corp.)-An HP insurance subsidiary

NHPCO (National Hospice and Palliative Care Organization, Inc.)-Founded in 1978, the National Hospice and Palliative Care Organization is the oldest and largest nonprofit public benefit organization devoted exclusively to hospice care. NHPCO is dedicated to promoting and maintaining quality care for terminally ill persons and their families, and to making hospice an integral part of the U.S. healthcare system.

NICE-Call center recording, tracking and archival software. NICE is not an acronym for anything.

NIST (National Institute of Standards and Technology)-Founded in 1901, NIST is a nonregulatory federal agency within the U.S. Department of Commerce's Technology Administration. NIST's mission is to develop and promote measurement, standards, and technology to enhance productivity, facilitate trade, and improve the quality of life.

NMEH (National Medicaid EDI Healthcare Workgroup)-A consortium of State Medicaid agencies and Fiscal Intermediaries who meet biweekly via teleconference to discuss Medicaid-specific HIPAA implementation issues. NMEH has established sub-workgroups that are involved in the analysis of the major Transaction Sets and related functional healthcare code-sets. CMS representatives also participate in the teleconferences and provide guidance and interpretation of Final and Proposed HIPAA Rules.

nominal group technique-A tool to bring a team in conflict to consensus on the relative importance of issues, problems, or solutions by completing individual importance ranking into a team's final priorities.

non-certified beds-Beds in an LTC facility that are not authorized or licensed for government reimbursement.

Non-Claim-Specific Accounts Receivable-Accounts Receivable not tied to a specific claim ICN, also known as a non-claim-specific adjustment. Examples include claim dropped from history, year-end settlements, and so on.

non-core contractors-Refers to the Medical Policy contractor and the TPL/Drug Rebate contractor.

non-core services-Refers to Service Packages #2 and #3.

non-covered service-The service does not meet the requirements of a Medicaid benefit category, or the service is excluded from coverage or is not reasonable and necessary.

Non-Emergency Medical Transportation (NEMT)-Non-commercial medical transportation provided to beneficiaries in private vehicles, including their own.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)-Drugs with in a class that reduces inflammation and pain due to various causes (i.e., arthritis, trauma, neuralgia) by inhibiting prostaglandin response.

NOOH (Notice of Opportunity for Hearing)-Notification that a drug product is the subject of a notice of opportunity for hearing issued under Section 505(e) of the Federal Food, Drug, and Cosmetic Act and published in the Federal Register on a proposed order of FDA to withdraw its approval for the drug product because it has determined that the product is less than effective for all its labeled indications.

North Central Region-Effective January 1, 2007, an enrollment area in North Central Indiana that includes the following counties: Elkhart, Fulton, Marshall, Pulaski, St. Joseph, and Starke. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007, and Care Select was effective March 1, 2008.

Northeast Region-Effective January 1, 2007, an enrollment area in Northeast Indiana that includes the following counties: Adams, Allen, DeKalb, Huntington, Kosciusko, LaGrange, Miami, Noble, Steuben, Wabash, Wells, and Whitley. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007, and Care Select was effective March 1, 2008.

Northern Region - Terminated December 31, 2006-Effective prior to January 1, 2007, a Hoosier Healthwise enrollment area in Northern Indiana that includes the following counties: Adams, Allen, Cass, Dekalb, Elkhart, Fulton, Huntington, Jasper, Kosciosko, LaGrange, LaPorte, Marshall, Miami, Newton, Noble, Porter, Pulaski, St. Joseph, Starke, Steuben, Wabash, Wells, White and Whitley.

Northwest Region-Effective January 1, 2007, an enrollment area in Northwest Indiana that includes the following counties: Jasper, Lake, LaPorte, Newton, and Porter. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007, and Care Select was effective March 1, 2008.

Notice of Opportunity for Hearing (NOOH)-Notification that a drug product is the subject of a notice of opportunity for hearing issued under Section 505(e) of the Federal Food, Drug, and Cosmetic Act and published in the Federal Register on a proposed order of FDA to withdraw its approval for the drug product because it has determined that the product is less than effective for all its labeled indications.

NPI (National Provider Identifier)-The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for health care providers. The NPI Final Rule issued January 23, 2004 adopted the NPI as this standard.

The provider's NPI will not change and will remain with the provider regardless of job or location changes.

NPI crosswalk-NPI to legacy Provider ID crosswalk.

NPI Dissemination-The release or disclosure of NPI-related information that is contained in NPPES to an individual or entity that is permitted to receive such information.

NPI Information Exchange-Refers to the ability of an individual or organization to disclose or distribute NPIs and NPI-related information to another individual or organization,

NPI Rule, NPI Final Rule-The Final Rule adopting the HIPAA standard requiring a unique health identifier for healthcare providers.

NPIN (National Provider Identifier Number)-A 10-position numeric identifier with a check digit in the last position to help detect keying errors. The NPI contains no embedded intelligence; that is, it contains no information about the healthcare provider such as the type of healthcare provider or State where the healthcare provider is located.

NPPES (National Plan and Provider Enumeration System)-CMS-funded entity that assigns the 10-digit NPI. The NPPES processes the applications and updates, ensures the uniqueness of the healthcare provider and generates the NPIs. See FOX Systems Inc.

NPS (National Provider System)-The administrative system for supporting a national provider registry.

An application system through which users have the capability to assign NPIs to providers and to access/update provider identification data.

NSAIDS (Non-Steroidal Anti-Inflammatory Drugs)-Drugs with in a class that reduces inflammation and pain due to various causes (i.e., arthritis, trauma, neuralgia) by inhibiting prostaglandin response.

NSF (National Standard Format)-Was designed to standardize and increase the submission of electronic claims and coordination of benefits exchange. The NSF is used to electronically submit healthcare claims and encounter information from providers of healthcare services to payers. It is also used to exchange healthcare claims and payment information between payers with different payment responsibility.

NUBC (National Uniform Billing Committee)-The principal goal of the NUBC is to develop, promote, and maintain a uniform standard data set and format(s), which can be used by the institutional healthcare community to transmit related charge and claim information to all third-party payers. With the data set operational, one of the NUBC's major roles is to maintain the integrity of the UB-04 data set. In addition, the NUBC serves as the forum for discussions that lead to mutually agreed data elements for the claim as well as the data elements for other claim-related transactions.

The NUBC parallels the National Uniform Claim Committee (NUCC) for the non-institutional healthcare community.

NUCC (National Uniform Claim Committee)-An organization, chaired and hosted by the American Medical Association, that maintains the CMS-1500 claim form and a set of data element specifications for professional claims submission via the CMS-1500 claim form, the Professional EMC NSF, and the X12 837. The NUCC also maintains the Provider Taxonomy Codes and has a formal consultative role under HIPAA for all transactions affecting non-dental non-institutional professional healthcare services.

nurse practitioner-A registered nurse who has advanced training in a specialized nursing field such as geriatrics or pediatrics.

nursing facility (NF)-Facility licensed by and approved by the State in which eligible individuals receive nursing care and appropriate rehabilitative and restorative services under the Title XIX (Medicaid) Long Term Care Program.

Also referred to as ECF, NH, and LTC.

Nursing Facility For Mental Health (NF/MH)-Any nursing facility that provides room, board, and all routine services and supplies for beneficiaries with mental health needs.

Nursing Facility For Skilled Nursing (NFSN)-Any nursing facility that provides room, board, and all routine services and supplies for beneficiaries with skilled nursing needs.

nursing facility waiver (NF waiver)-A waiver of the Medicaid's state plan granted under Section 1915c of the Social Security Act that allows Indiana to provide community-based services to adults as an alternative to NF care.

nursing home (NH)-Also referred to as ECF, NF, and LTC.

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object-An individual data source such as a provider number, procedure code, or date of service.

OBRA or OBRA-90 (Omnibus Budget Reconciliation Act or Omnibus Budget Reconciliation Act of 1990)-Establishes the drug rebate program.

occurrence code-Together with associated date fields, defines a specific event relating to a UB-04 bill that may affect payer processing. The codes are used to determine liability, coordinate benefits, and administer subrogation clauses in benefit programs.

occurrence span code (OSC)-Occurrence span codes and corresponding dates are used to identify events that relate to the payment of claims.

OCR (optical character recognition)-A device that reads letters or numbers from a page and converts them to computerized data, bypassing data entry.

OET (OMPP Operational Effectiveness Team)-A group of individuals from OMPP, Myers and Stauffer, HP, and Health Care Excel, Inc. (HCE) who are responsible for review, approval, and denial of change requests. This group meets weekly at OMPP.

OFC (Office of Family and Children)-Replaced by OFR; OFR replaced by CDFR.

Office of Children's Health Insurance Program-The office within the Indiana Families and Social Services Administration that administers the Children's Health Insurance Program (CHIP). The CHIP office is responsible for developing the policies and procedures for Hoosier Healthwise Package C enrollees.

Office of Family Resources (OFR)-County offices of FSSA servicing families and children through Temporary Assistance for Needy Families (TANF), food stamps, housing, child care, foster care, adoption, energy assistance, homeless services, and job programs.

Formerly CDFC, now CDFR.

Office of Medicaid Policy and Planning (OMPP)-The office within the Indiana Families and Social Services Administration that administers the Indiana Health Coverage Programs. The OMPP is responsible for developing the policies and procedures for the health plan programs, which include Hoosier Healthwise, Care Select, and Healthy Indiana Plan.

OFR ([Local County] Office of Family Resources)-County offices of FSSA servicing families and children through Temporary Assistance for Needy Families (TANF), food stamps, housing, child care, foster care, adoption, energy assistance, homeless services, and job programs.

Formerly CDFC, now CDFR.

OGB (OMPP Governance Board)-A group of individuals who are responsible for review, approval, and denial of change requests to change policy.

Omni -A point-of-sale device used by providers to scan member ID cards to determine eligibility.

Omnibus Budget Reconciliation Act or Omnibus Budget Reconciliation Act of 1990 (OBRA or OBRA 90)-Establishes the drug rebate program.

OMPP (Office of Medicaid Policy and Planning)-The office within the Indiana Families and Social Services Administration that administers the Indiana Health Coverage Programs. The OMPP is responsible for developing the policies and procedures for the health plan programs, which include Hoosier Healthwise, Care Select, and Healthy Indiana Plan.

OMPP Governance Board (OGB)-A group of individuals who are responsible for review, approval, and denial of change requests to change policy.

OMPP Operational Effectiveness Team (OET)-A group of individuals from OMPP, Myers and Stauffer, HP, and Health Care Excel, Inc. (HCE) who are responsible for review, approval, and denial of change requests. This group meets weekly at OMPP.

OnDemand-An IBM product that processes the print output of application programs, extracts index fields from the data, stores the index information in a relational database, and stores one or more copies of the data in the system. This allows users to archive newly created and frequently accessed reports or images on high-speed disk storage volumes and automatically migrate them to other types of storage volumes as the reports age.

OOS (out-of-state)-Billing for an IHCP member from a facility or physician outside Indiana or from a military facility.

open formulary-A list of drugs covered for a particular program; use is not exclusively restricted to this list.

optical character recognition (OCR)-A device that reads letters or numbers from a page and converts them to computerized data, bypassing data entry.

optional services or benefits-More than 30 different services that a state can elect to cover under a state Medicaid plan. Examples include personal care, rehabilitative services, prescribed drugs, therapies, diagnostic services, intermediate care facilities for the mentally retarded (ICFs/MR), targeted case managed, and so forth.

organization healthcare providers (NPI)-The National Provider Identifier (NPI) rule defines "organization healthcare providers" as providers who are not individuals (persons). These are classified as entity type 2 providers. Examples are hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, health maintenance organizations, suppliers of durable medical equipment, and pharmacies.

Some healthcare provider organizations are made up of components or business units that function somewhat independently of their "parent" healthcare organizations. These components, which are referred to as "subparts" in the regulation, might conduct their own standard transactions at the same or different addresses than the parent organizations, and might furnish types of service different from those of the parent organization. The subparts might be required by federal regulations to have unique identifiers for billing purposes. Organizations must determineation the status of their subparts and apply for NPIs as they deem appropriate.

The Work Group for Electronic Data Interchange (WEDI) has a white paper on this topic that can help covered entities decide.

OSC (occurrence span code)-Occurrence span codes and corresponding dates are used to identify events that relate to the payment of claims.

OSC 77-occurrence span code form.

OTC drug (over-the-counter drug)-A drug classification used for pharmaceuticals that do not require prescriptions.

other developmental-A condition or illness, such as cerebral palsy, epilepsy, or autism (but excluding the mental disability, illness, and infirmities of aging) that is manifested before age 22. The condition may be expected to continue indefinitely and substantially limit three or more of the following:

Self-care
Understanding and using language
Learning and adapting
Mobility
Self-direction in setting goals and undertaking activities to accomplish those goals
Living independently
Economic self-sufficiency

The need for special, interdisciplinary, or generic care, treatment, or other services which are lifelong or of an extended duration; and which are individually planned and coordinated.

other insurance-Any health insurance benefits that patients possess in addition to Medicaid or Medicare; primary insurance payers.

other processing agency-Any organization or agency that performs IHCP functions under the direction of the single state agency. The single state agency may perform all IHCP functions itself, or it may delegate functions to other agencies.

outcome measures-Assessments that gauge the effect or results of treatment including the patient's perception of how well function is restored, quality of life and functional status, and objective measures of mortality, morbidity, and health.

outcomes-Results achieved through a healthcare service, prescription drug use, or medical procedure.

outcomes management-Improving healthcare results, typically by modifying practices in response to data gleaned through outcomes measurement, then remeasuring and modifying again, often in a formal program of continuous quality improvement.

outcomes research-Studies aimed at measuring the effect of a given product, procedure, or medical technology on health or costs.

outlier-An additional payment made for exceptionally long or expensive hospital stays.

out-of-state (OOS)-Billing for an IHCP member from a facility or physician outside Indiana or from a military facility.

out-of-state/IFSSA Region-An enrollment area for managed-care programs. Out-of-state regions were created to auto-assign members to primary medical providers (PMPs) outside Indiana, as designated by the Indiana Family and Social Services Administration (FSSA). These areas are excluded from out-of-state prior authorization (PA) requirements and required to follow in-state (Indiana) PA requirements. The cities designated by the FSSA are as follows:

Chicago, Illinois
Sturgis, Michigan
Danville, Illinois
Cincinnati, Ohio
Watseka, Illinois
Hamilton, Ohio
Louisville, Kentucky
Harrison, Ohio
Owensboro, Kentucky
Oxford, Ohio

outpatient-A patient who is receiving care at a hospital or other health facility without being admitted. Outpatient normally does not include patients receiving services from a facility that does not also give inpatient care.

outpatient care, outpatient services-Hospital services and supplies furnished and billed by a hospital in connection with the care of a patient who is not a registered bed patient.

overpayment-An amount included in a reimbursement to a provider resulting from the failure of the contractor to use available information or to process correctly.

override-Forced bypassing of a claim error. This may be done manually by a resolutions clerk or with the use of codes submitted on a claim, such as DAW code 6 or TPL override codes.

over-the-counter drug (OTC drug)-A drug classification used for pharmaceuticals that do not require prescriptions.

overutilization-Use of health or medical services beyond what is considered normal.

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PA (prior authorization)-Some Medicaid services require providers to request approval of certain types or amounts of services from the State before providing those services. The medical services contractor and State medical consultants review PAs for medical necessity, reasonableness, and other criteria. The PA must be obtained within a certain time period before services are provided, except in certain instances, such as goal-directed therapy, home health services, and dentures for those over 21.

PA (public assistance)-A generic term that refers to an individual receiving cash benefits from the State.

Package C-A part of the Balanced Budget Act of 1997 that extends the Medicaid program to children ages 0 to 19 years whose family income is at the federal poverty level (FPL). Also known as Children's Health Insurance Program (CHIP).

paid amount-Net amount of money allowed by the IHCP.

paid claim-A claim processed through the adjudication and payment cycles that has had some dollar amount paid to the provider (although the amount may be less than the amount billed by the provider). Includes claims "paid" at zero dollars.

In the MMIS, the term "paid" refers to a claim with a payment status of either "paid" or "denied."

paid claims history file-History of all claims - both paid and denied - received by the IHCP and handled by the computer processing system through a terminal point.

paid encounter data table-A record of all encounter data that has been processed and priced by IndianaAIM. With the exception of maternal delivery claims, paid encounter data does not result in a financial transaction. Information from paid encounter data is included in service limitation auditing and utilization analysis.

Palmetto GBA, or Palmetto Government Benefits Administrators, LLC., or GBA (Government Benefits Administrators)-One of the largest Medicare Administrative Contractors (MACs) in the nation, serving providers, beneficiaries, and other Medicare partners. A wholly owned subsidiary of Blue Cross Blue Shield of South Carolina.

panel hold-The term used in the managed-care subsystem to reflect that a primary medical provider is barred from receiving new assignments.

panel size-The total number of members a primary medical provider (PMP) has agreed to accept for each of the managed-care programs.

paper claim-A claim for services that was submitted on paper rather than via electronic means; also referred to as hard copy or manual claims.

paperless claims-Claims sent by electronic means; equivalent to electronic media claims (EMC), electronic claim submission (ECS), electronic claim capture (ECC), and similar terms denoting claim transmittal via electronic media.

Paperless Inquiry and Claims System (PICS)-A computer application providers use to access eligibility verification, adjustment request, claim and financial status, prior authorization requests, and claim entry.

Part A or Medicare Part A-The part of Medicare that covers hospice care, home healthcare, skilled NFs, and inpatient hospital stays. Part A helps pay for medically necessary inpatient hospital care; and after a hospital stay, for inpatient care in a skilled NF; for home care by a home health agency; or hospice care by a licensed and certified hospice agency.

Part B or Medicare Part B-The part of Medicare that helps pay for doctors, outpatient hospital care, and other medical services not requiring hospitalization. Part B helps pay for medically necessary physician services, outpatient hospital services, outpatient physical therapy, and speech pathology services, and a number of other medical services and supplies that are not covered by the hospital insurance. Part B pays for certain inpatient services if the beneficiary does not have Part A.

Part D, Medicare Part D, or Medicare D-The Medicare Prescription Drug Improvement and Modernization Act of 2003, also known as the Medical Reform Act, established a voluntary drug benefit for Medicare beneficiaries and created a new Medicare Part D. The program provides elderly and disabled people already on Medicare access to drug coverage as of January 2006.

Medicare Part D prescription drug plans (PDPs) are government-sponsored insurance policies, issued by commercial insurance companies, designed to help defray the costs of prescription drugs. Beginning November 15, 2005, anyone with Medicare Part A or Part B could purchase a prescription drug benefit plan through private insurance companies. Individuals who receive full Medicaid and Medicare benefits are automatically enrolled in the Medicare prescription drug coverage.

participant-One who is involved with the IHCP as either a provider or a member.

participating members-Individuals who receive Title XIX services during a specified period of time.

participating providers-Healthcare entities that furnish Title XIX services during a specified period of time.

participation agreement-A contract between a provider of medical service and the state that specifies the conditions and services the facility must provide to serve IHCP members and receive reimbursement for those services.

PAS (pre-admission screening)-A program that determines a beneficiary's required level of care and screens his or her potential for receiving community-based services as an alternative to nursing home placement.

PAS (Professional Activities Study)-Document of statistical healthcare data used for prior authorization guidelines.

PAS Form 4B (Pre-Admission Screening /PASRR Assessment Determination)-The assessment form received for Indiana residents to see if they meet the State criteria for facility placement.

PASRR (Pre-Admission Screening and Resident Review)-A set of federally required screening and evaluation services performed for long-term care residents, payable by the Medicaid program. Authorized by the Omnibus Budget and Reconciliation Act of 1987.

past filing limit (PFL)-Type of claim rejection that occurs when the provider files claims after the prescribed filing limit without documentation needed to waive the limit.

patient-A person receiving treatment or care from a physician or other health professional.

patient liability-A beneficiary's monetary obligation to a nursing facility that is determined by his or her income level.

pay and chase-Under certain circumstances for prenatal, pharmacy, and Early and Periodic Screening, Diagnosis and Treatment (EPSDT) claims, the claims are initially paid by the claims-processing system and then must accumulate to a predetermined threshold before being paid by the third-party insurance. In this situation, a claim is paid, despite coverage, and the carrier is billed (pay and chase).

payable codes-Approved procedure codes (those for services which will be provided once they have been approved) that have a dollar value attached to them for claims payment.

payer-In healthcare, an entity that assumes the risk of paying for medical treatments. This can be an uninsured patient, a self-insured employer, a health plan, or a health-maintenance organization (HMO).

payer of last resort-The insurance program that pays after all a patient's other insurance programs have paid for a service. Medicaid is usually the payer of last resort. Payments made by Native American money, such as those made by the Bureau of Indian Affairs, are made after Medicaid payment is made.

payment cycle-The processing of adjudicated claims to a paid or denied status. Users determine the frequency of running payment cycles. Most state agencies pay providers weekly.

payouts-Payments to providers or other entities (such as insurance companies) for monies owed that are not claim-related. Payouts are the results of cost settlements or return excess refunds to the provider.

PBM (pharmacy benefits manager)-A person or organization applying managed-care principles to prescription drug programs to attain optimal and cost-effective drug prescribing and use. PBM functions can include: (1) claims processing and adjudication; (2) data management, reporting, and trending; (3) formulary management and clinical review services; (4) prospective Drug Utilization Review (ProDUR); and (5) drug rebate management.

PCA (Physician's Corporation of America)-A health maintenance organization (HMO) providing health benefits to Medicaid clients.

PCCM (primary care case management) Members in the PCCM delivery system are linked to primary medical providers (PMPs) that act as a gatekeepers by providing and arranging for most of the members' medical care. The PMP receives an administrative fee per month for every member and is reimbursed on a fee-for-service (FFS) basis. PMPs may be physicians, advanced registered nurse practitioners (ARNPs), local health departments, federally qualified health centers (FQHCs), rural health clinics (RHCs), or clinics. Beneficiaries either select or are assigned to the PCCM. Formerly known as the Primary Care Network (PCN).

PCN (primary care network)-See primary care case management (PCCM).

PCN (processor control number)--In relation to pharmacy.

PCP (primary care provider; primary care physician)-A physician (the majority of whose practice is devoted to internal medicine, family/general practice, and pediatrics), advanced registered nurse practitioner, health department, or clinic who manages a beneficiary's healthcare needs. An obstetrician/
gynecologist may also be considered a primary care physician.

PDCA Cycle-An adaptation of the Deming Cycle, which stresses that every improvement activity can best be accomplished by the following steps: plan, do, check, act.

PE (presumptive eligibility)-Provides prenatal ambulatory services to pregnant women while Medicaid eligibility is determined. An MCO and PMP are selected with the assistance of the enrollment broker during the enrollment process when presumptive eligibility is established by a certified Qualified Provider. Also known as qualified provider presumptive eligibility (QPPE).

PE (Provider Enrollment)-A unit within the fiscal agent that processes provider applications and maintains master files on all providers.

peer-A person or committee in the same profession as the provider whose claim is being reviewed.

peer review-An activity 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.

pending (claim)-Action of postponing adjudication of a claim until a later processing cycle.

pending review status (CR)-Assigned to a change request when it is slated for review in the weekly OMPP Operational Effectiveness Team (OET) meeting.

per diem-Daily rate charged by institutional (such as a hospital or nursing home) providers.

per member per month (PM/PM or PMPM)-Unit of measure related to each beneficiary for each month the member is enrolled in a managed-care plan. The calculation is as follows: # of units divided by MM.

performing provider-Party who actually delivers service or treatment.

PERS (personal emergency response system)-An electronic device that enables consumers to secure help in an emergency.

Personal Assistance Services-Support provided through the Medicaid State Plan to employ individuals with disabilities.

personal care-Optional Medicaid benefit that allows a state to provide attendant services to help functionally impaired individuals perform the activities of daily living (for example, bathing, dressing, feeding, grooming). Indiana provides primary home care services under this option.

personal emergency response system (PERS)-An electronic device that enables consumers to secure help in an emergency.

PFL (past filing limit)-Type of claim rejection that occurs when the provider files claims after the prescribed filing limit without documentation needed to waive the limit.

pharmacist-A professional qualified by education and authorized by law to prepare, preserve, compound, dispense, and instruct in the use of drugs.

pharmacy benefits manager, pharmacy benefits management (PBM)-A person or organization applying managed-care principles to prescription drug programs to attain optimal and cost-effective drug prescribing and use. PBM functions can include: (1) claims processing and adjudication; (2) data management, reporting, and trending; (3) formulary management and clinical review services; (4) prospective Drug Utilization Review (ProDUR); and (5) drug rebate management.

pharmacy point of service (pharmacy POS)-A system that enables Medicaid providers to submit electronic pharmacy claims online in real time. The electronic claim submission verifies beneficiary eligibility; including other health insurance coverage; monitors Medicaid drug policies; and screens claims against beneficiary medical and prescription history within the Medicaid system. Once these processes are complete, the provider receives an electronic response indicating payment or denial within seconds of submitting the claim. Also referred to as point of service, or as point of sale.

PHC (primary home care)-IHCP-funded community care that provides personal care services to more than 40,000 aged or disabled people in Indiana. PHC is provided as an optional state plan benefit.

PHCSP (preventive healthcare services provider)-A provider of well-child care, prenatal care, or care coordination services.

phenylketonuria (PKU)-A genetic disorder that can cause problems with brain development, leading to seizures and progressive mental retardation. It can be controlled with diet.

PHI (protected health information)-Individually identifiable health information that is communicated in the following ways:

Transmitted by electronic media, which includes Internet, extranet, leased lines, dial-up lines, private networks, magnetic tape, disk, or compact disk (45 CFR 162.103).
Maintained in any electronic media.
Transmitted or maintained in any other form or medium, including oral communication or on paper.

PHO (physician hospital organization)-An organization whose board is composed of physicians, but with a hospital member, that negotiates contracts with insurance carriers and self-insured employers to provide healthcare services to program enrollees.

PHS (Public Health Service)-Group of providers that is exempt from the drug rebate process.

Physically Disabled Waiver-Home- and Community-Based Services (HCBS) classification for beneficiaries age 16 to 64 who are physically disabled.

physician hospital organization (PHO)-An organization whose board is composed of physicians, but with a hospital member, that negotiates contracts with insurance carriers and self-insured employers to provide healthcare services to program enrollees.

Physician's Corporation of America (PCA)-A health maintenance organization (HMO) providing health benefits to Medicaid clients.

PIC (pricing indicator code)-Determines reimbursement restrictions for drug and procedure codes.

PIC (procedure identification code)-A procedure code and modifiers to identify a service for reporting purposes.

pica-A disorder that entails persistent eating of nonnutritive substances for a period of at least one month at an age when this behavior is developmentally inappropriate (greater than 18-24 months). Pica may also include the mouthing of nonnutritive substances. Individuals with pica have been reported to mouth or ingest a wide variety of nonfood substances, including clay, dirt, sand, stones, pebbles, hair, feces, lead, laundry starch, vinyl gloves, plastic, pencil erasers, ice, fingernails, paper, paint chips, coal, chalk, wood, plaster, light bulbs, needles, string, and burnt matches.

PICS (Paperless Inquiry and Claims System)-A computer application providers use to access eligibility verification, adjustment request, claim and financial status, prior authorization requests, and claim entry.

PICTURE-COBOL PICTURE (PIC) clause. Describes how data is presented on transmission (Companion Guides).

PIV (Project Invision)-An HP application used to track projects, tasks, task issues, and time spent on project tasks.

PKU (phenylketonuria)-A genetic disorder that can cause problems with brain development, leading to seizures and progressive mental retardation. It can be controlled with diet.

place of service (POS)-The location where treatment was rendered, such as office, home, emergency room, and so forth.

plan of care (POC)-A formal plan developed to address the needs of individuals who are eligible for long-term care and have elected home- and community-based services instead of nursing facility services. The plan must include services to be provided and their frequency, entities or people who will provide each service, and the cost of each service.

PM/PM or PMPM (per member per month)-Unit of measure related to each beneficiary for each month the member is enrolled in a managed-care plan. The calculation is as follows: # of units ¸ MM.

PMI (Project Management Institute) Organization for the certification of project management experts.

PMP (primary medical provider)-A physician who approves and manages the care and medical services provided to IHCP members assigned to the PMP's care.

PMP (primary medical provider) disenrollment letter-Written communication to the primary medical provider (PMP) confirming the effective date of a PMP disenrollment from a managed-care organization (MCO) or Care Select.

PNCC (Prenatal Care Coordination Program)-In Indiana, Medicaid reimburses for prenatal care coordination. This program works to lower infant mortality rates (an Indiana State Health Department Public Health Priority). Staff from the State Maternal and Child Health Services (MCHS) collaborate in training, planning, evaluating outcomes, ensuring quality, and building infrastructure with other state and local agencies.

POC (plan of care)-A formal plan developed to address the needs of individuals who are eligible for long-term care and have elected home- and community-based services instead of nursing facility services. The plan must include services to be provided and their frequency, entities or people who will provide each service, and the cost of each service.

point of sale (POS)-A billing system that uses swipe cards or personal computers to bill for services rendered at the time and place of service.

Point of sale/service device-A small box with an attached printer that allows providers to electronically access current beneficiary eligibility information.

point of service (POS)-A system that enables Medicaid providers to submit electronic pharmacy claims online in real time. The electronic claim submission verifies beneficiary eligibility; including other health insurance coverage; monitors Medicaid drug policies; and screens claims against beneficiary medical and prescription history within the Medicaid system. Once these processes are complete, the provider receives an electronic response indicating payment or denial within seconds of submitting the claim. Also referred to as pharmacy point of service, or as point of sale.

A billing system that uses swipe cards or personal computers to bill for services rendered at the time and place of service.

pool or risk pool-An account defined by size, geographic location, claim dollars that exceed x level per individual, and so forth, to which revenue and expenses are posted. A risk pool attempts to define expected claim liabilities of a given account, as well as required funding to support the claim liability.

POS (place of service)-The location where treatment was rendered, such as office, home, emergency room, and so forth.

POS (point of sale; point of service)-A system that enables Medicaid providers to submit electronic pharmacy claims online in real time. The electronic claim submission verifies beneficiary eligibility; including other health insurance coverage; monitors Medicaid drug policies; and screens claims against beneficiary medical and prescription history within the Medicaid system. Once these processes are complete, the provider receives an electronic response indicating payment or denial within seconds of submitting the claim. Also referred to as pharmacy point of service.

A billing system that uses swipe cards or personal computers to bill for services rendered at the time and place of service.

post and pay-The process by which an edit is attached to a claim for informational purposes only.

poverty level-A statistical measure that indicates the cash income a family needs to purchase a "minimally adequate" market basket of goods and services. The threshold is adjusted for family size and updated every February for inflation. It is a nationwide standard.

PPA (prior period adjustment)-In relation to drug rebate.

PPO (preferred provider organization)-An arrangement between a provider network and a health insurance carrier or a self-insured employer. Providers generally accept reimbursements that are less than traditional fee-for-service (FFS) payments in return for a potentially greater share of the patient market. PPO enrollees are not required to use the preferred providers, but are given strong financial incentives, such as reduced coinsurance and deductibles, to do so. Providers do not accept financial risk for the management of care. See exclusive provider organization (EPO).

PR (provider relations)-Function or activity within an organization or contractor that handles relationships with entities that render healthcare services.

practitioner-An individual provider who practices a health or medical service profession.

pre-admission screening (PAS)-A program that determines a beneficiary's required level of care and screens his or her potential for receiving community-based services as an alternative to nursing home placement.

Pre-Admission Screening and Resident Review (PASRR)-A set of federally required screening and evaluation services performed for long-term care residents, payable by the Medicaid program. Authorized by the Omnibus Budget and Reconciliation Act of 1987.

preferred provider organization (PPO)-An arrangement between a provider network and a health insurance carrier or a self-insured employer. Providers generally accept reimbursements that are less than traditional fee-for-service (FFS) payments in return for a potentially greater share of the patient market. PPO enrollees are not required to use the preferred providers, but are given strong financial incentives, such as reduced coinsurance and deductibles, to do so. Providers do not accept financial risk for the management of care. See exclusive provider organization (EPO).

premium-The periodic payment (such as monthly, quarterly) made to an insurance company to keep a policy in force.

Amount due from a member in order to be eligible for Package C.

premium billing-Eligible HealthWave consumers' income level is assessed to determine if premiums will be required from them. Monthly premiums of $0, $10, or $15 can be required without regard to the number of children eligible. The premium amount is entered in KAECSES by the FSSA. Premium invoices are sent and paid for in the month of eligibility received.

premium vendor-A provider of premium collection services for the Children's Health Insurance Program (CHIP) and the Medicaid for Employees with Disabilities (M.E.D. Works) program.

premium vendor -contract An agreement with the Indiana Family and Social Services Administration (FSSA) to maintain historical and current payment records for all individuals, and to generate and send monthly statements requesting payment.

Prenatal Care Coordination Program (PCCP)-In Indiana, Medicaid reimburses for prenatal care coordination. This program works to lower infant mortality rates (an Indiana State Health Department Public Health Priority). Staff from the State Maternal and Child Health Services (MCHS) collaborate in training, planning, evaluating outcomes, ensuring quality, and building infrastructure with other state and local agencies.

prenatal care coordinator-Person who has satisfied the requirements to obtain the Care Coordination Certificate from the National Association of Social Workers (NASW).

prenatal case management-See Prenatal Care Coordination Program (PNCC).

prepayment review-Provider claims suspended temporarily before final adjudication for dispositioning and manual review by the Health Care Excel (HCE) Surveillance and Utilization Review (SUR) Unit.

prescriber-Anyone with the authority to write prescriptions, including physicians, physician assistants, nurse practitioners, optometrists, podiatrists, psychiatrists, and dentists.

prescription medication-Drug approved by the U.S. Food and Drug Administration (FDA) that can, under federal or state law, be dispensed only with a prescription from a licensed prescriber..

presumptive eligibility (PE)-Provides prenatal ambulatory services to pregnant women while Medicaid eligibility is determined. An MCO and PMP are selected with the assistance of the enrollment broker during the enrollment process when presumptive eligibility is established by a certified Qualified Provider. Also known as qualified provider presumptive eligibility (QPPE).

preventive care-Comprehensive care emphasizing prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization, and well-person care.

preventive healthcare services provider (PHCSP)-A provider of well-child care, prenatal care, or care coordination services.

pricing-Determination of the IHCP allowable payment amount. Procedures that suspend for pricing may require a cost invoice to determine pricing.

pricing indicator code (PIC)-Determines reimbursement restrictions for drug and procedure codes.

primary care-Basic or general healthcare traditionally provided by family practice, general practice, pediatrics, and internal medicine.

Primary Care Case Management (PCCM)-Members in the PCCM delivery system are linked to primary medical providers (PMPs) that act as a gatekeepers by providing and arranging for most of the members' medical care. The PMP receives an administrative fee per month for every member and is reimbursed on a fee-for-service (FFS) basis. PMPs may be physicians, advanced registered nurse practitioners (ARNPs), local health departments, federally qualified health centers (FQHCs), rural health clinics (RHCs), or clinics. Beneficiaries either select or are assigned to the PCCM. Formerly known as the Primary Care Network (PCN).

primary care network (PCN)-See primary care case management (PCCM).

primary care physician; primary care provider (PCP)-A physician (the majority of whose practice is devoted to internal medicine, family/general practice, and pediatrics), advanced registered nurse practitioner, health department, or clinic who manages a beneficiary's healthcare needs. An obstetrician/
gynecologist may also be considered a primary care physician.

primary home care (PHC)-IHCP-funded community care that provides personal care services to more than 40,000 aged or disabled people in Indiana. PHC is provided as an optional state plan benefit.

primary medical provider (PMP)-A physician who approves and manages the care and medical services provided to IHCP members assigned to the PMP's care.

primary medical provider (PMP) disenrollment letter-Written communication to the primary medical provider (PMP) confirming the effective date of a PMP disenrollment from a managed-care organization (MCO) or Care Select.

prime contractor-Organization that works directly with the State to perform the work specified.

prior authorization (PA)-Some Medicaid services require providers to request approval of certain types or amounts of services from the State before providing those services. The medical services contractor and State medical consultants review PAs for medical necessity, reasonableness, and other criteria. The PA must be obtained within a certain time period before services are provided, except in certain instances, such as goal-directed therapy, home health services, and dentures for those over 21.

prior period adjustment (PPA)-In relation to drug rebate.

prior review and approval-The procedure for prior review and authorization, modification, or denial of payment for covered medical services and supplies within IHCP's allowable charges. It is based on medical reasonableness, necessity, and other criteria as described in the IAC Covered Services Rule and Medical Policy Rule.

private trust-Fund available to pay medical expenses.

PRN (Pro re nata)-Latin, meaning "when necessary" or "as needed," especially when referring to dispensing or taking medications.

Pro re nata (PRN)-Latin, meaning "when necessary" or "as needed," especially when referring to dispensing or taking medications.

PROC/NDC-The procedure, revenue code, or National Drug Code on the claim record.

procedure-Specific, singular medical service performed for the express purpose of identification or treatment of the patient's condition.

A numeric or alphanumeric code used to describe the specific service rendered to a patient by a provider.

procedure code-Identification of a specific service using the appropriate series of coding systems such as the Current Dental Terminology (CDT), Current Procedural Terminology (CPT^®), Healthcare Common Procedure Coding System (HCPCS), or ICD-9-CM.

procedure identification code (PIC)-A procedure code and modifiers to identify a service for reporting purposes.

processed claim-Claim where a determination of payment, nonpayment, or pending has been made, and the remittance has been sent.

processor control number (PCN)-In relation to pharmacy.

ProDUR (Prospective Drug Utilization Review)-Identifying potential overuse before dispensing a drug. The Medicaid Management Information System (MMIS) has criteria within the system that compare the information on a point-of-sale (POS) claim coming in for payment with the drug claim information on history for the same beneficiary.

Professional Activities Study (PAS)-Document of statistical healthcare data used for prior authorization guidelines.

professional component-The portion of a service that is direct patient care provided by the physician or audiologist, such as the interpretation of an x-ray, lab test, or other diagnostic procedure. This is indicated by modifier 26 when billed on a claim with a code that includes both technical and professional components.

profile-Total view of a provider's charges or of services rendered to a member.

program director-Person at the contractor's local office who is responsible for overseeing the administration, management, and daily operation of the Medicaid Management Information System (MMIS) contract.

Project Invision (PIV)-An HP application used to track projects, tasks, task issues, and time spent on project tasks.

Project Management Institute (PMI)-Organization for the certification of project management experts.

Project Workbook (PWB)-HP proprietary Web application that serves as a repository of HP interChange information and contains administrative, application, and project information.

Prospective Drug Utilization Review (ProDUR)-Identifying potential overuse before dispensing a drug. The Medicaid Management Information System (MMIS) has criteria within the system that compare the information on a point-of-sale (POS) claim coming in for payment with the drug claim information on history for the same beneficiary.

prosthetic devices-Devices that replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning body organ or limb.

protected health information (PHI)-Individually identifiable health information that is communicated in the following ways:

Transmitted by electronic media, which includes Internet, extranet, leased lines, dial-up lines, private networks, magnetic tape, disk, or compact disk (45 CFR 162.103).
Maintained in any electronic media.
Transmitted or maintained in any other form or medium, including oral communication or on paper.

provider-Person, group, agency, or other legal entity that is enrolled in and renders covered services to IHCP members.

provider agreement-A contract between the OMPP and an entity that renders healthcare services, setting out the terms and conditions of a provider's participation in the IHCP. It must be signed by the provider before any provider reimbursement takes place.

provider category of service-A code on claims that indicates the type of services given by the provider and the specific categories of services a provider may bill for.

Provider Enrollment (PE)-A unit within the fiscal agent that processes provider applications and maintains master files on all providers.

provider enrollment application-Required document for all providers who render services to IHCP members.

provider manual-Primary source document for IHCP providers.

provider networks-Organizations of healthcare providers that service managed care plans. Network providers are selected with the expectation that they deliver care inexpensively, and enrollees are channeled to network providers to control costs.

provider number-Unique individual or group number assigned to practitioners participating in the IHCP.

provider relations (PR)-Function or activity within an organization or contractor that handles relationships with entities that render healthcare services.

provider specialty (PS)-A code that specifies the type of service a provider renders.

provider taxonomy code-An alphanumeric code, 10 characters in length, structured into three distinct levels including provider type, classification, and area of specialization. The Health Care Provider Taxonomy Code Set allows a single provider (individual, group or institution) to identify its specialty category. The Health Care Provider Taxonomy Code Set is maintained by the National Uniform Claim Committee (NUCC).

provider type-A general code that indicates the type of service a healthcare entity performs.

PS (provider specialty)-A code that specifies the type of service a provider renders.

psychiatric hospital-An institution that is primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill persons.

public assistance (PA)-A generic term that refers to an individual receiving cash benefits from the State.

Public Health Service (PHS)-Group of providers that is exempt from the drug rebate process.

purged-Claims are removed from claims processing history files according to specific criteria after 36 months from the claim's last financial date. Claims data is online for up to seven years.

Refers to moving data from the master files to the archive files. For example, beneficiary eligibility records may be purged if there is no activity within a three-year period.

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QA/QC (quality assurance/quality control)-Interrelated methods of monitoring the services that managed-care organizations (MCOs) arrange or administer for their enrollees.

A State-requested review of the fiscal agent's internal operations.

A process of validating the output of Medicaid Management Information System (MMIS) subprocesses, whether the correct payment of a claim, the result of an eligibility determination, or the collection of third-party liability.

QARI (Quality Assurance Reform Initiative)-Guidelines established by the federal government for quality assurance in Medicaid managed-care plans.

QDWI (Qualified Disabled Working Individual)-A federal category of Medicaid eligibility for disabled individuals whose incomes are less than 200 percent of the federal poverty level.

Certain formerly disabled persons who lost Medicare benefits because of their return to work are allowed to purchase Medicare Part A coverage. The State Medicaid Program must pay the Part A premium for those individuals entitled to enroll in Part A if their income does not exceed twice the SSI limit and they are not otherwise eligible for Medicaid benefits.

QI (quality improvement)-A continuous process that identifies problems in healthcare delivery, tests solutions to those problems, and constantly monitors the solutions for improvement.

QIC (Quality Improvement Committee)-The committee established by the Office of Medicaid Polity and Planning (OMPP) that provides oversight for the appropriateness and quality of care provided to enrollees by establishing standards and guidelines for the provision of care. The QIC is responsible for integrating the quality improvement process and services as a coordinating and advisory body.

QMB (qualified Medicare beneficiary)-A federal category of Medicaid eligibility for aged, blind, or disabled individuals entitled to Medicare Part A whose incomes are less than 100 percent of the federal poverty level and whose assets are less than twice the Supplementary Security Income (SSI) asset limit. Medicaid benefits include payment of Medicare premiums, coinsurance, and deductibles only.

A State program that pays for a beneficiary's Medicare premiums, coinsurance, and deductible amounts, within limits.

QMB-Also (qualified Medicare beneficiary-also)-The QMB program is for people who receive Part A Medicare and whose income is below 100 percent of poverty. This program pays Medicare copayments and coinsurance amounts for medical services covered by Medicare, including copayments for Medicare-approved skilled nursing home care. It also pays the Medicare Part B premiums for eligible clients.

QPPE (qualified provider presumptive eligibility)-Provides prenatal ambulatory services to pregnant women while Medicaid eligibility is determined. An MCO and PMP are selected with the assistance of the enrollment broker during the enrollment process when presumptive eligibility is established by a certified Qualified Provider. Also known as presumptive eligibility (PE).

QT interval, QT syndrome-When the heart contracts, it emits an electrical signal. This signal can be recorded on an electrocardiogram (ECG or EKG) and produces a characteristic waveform. The different parts of this waveform are designated by letters - P, Q, R, S, and T. The Q-T interval represents the time for electrical activation and inactivation of the ventricles, the heart's lower chambers. A doctor can measure the time it takes for the Q-T interval to occur (in fractions of a second) and can tell if it occurs in a normal amount of time. If it takes longer than normal, it's called a prolonged Q-T interval.

Qualified Disabled Working Individual (QDWI)-A federal category of Medicaid eligibility for disabled individuals whose incomes are less than 200 percent of the federal poverty level.

qualified Medicare beneficiary (QMB)-A federal category of Medicaid eligibility for aged, blind, or disabled individuals entitled to Medicare Part A whose incomes are less than 100 percent of the federal poverty level and whose assets are less than twice the Supplementary Security Income (SSI) asset limit. Medicaid benefits include payment of Medicare premiums, coinsurance, and deductibles only.

A State program that pays for a beneficiary's Medicare premiums, coinsurance, and deductible amounts, within limits.

qualified Medicare beneficiary-also (QMB-Also)-The QMB program is for people who receive Part A Medicare and whose income is below 100 percent of poverty. This program pays Medicare copayments and coinsurance amounts for medical services covered by Medicare, including copayments for Medicare-approved skilled nursing home care. It also pays the Medicare Part B premiums for eligible clients.

qualified provider presumptive eligibility (QPPE)-Provides prenatal ambulatory services to pregnant women while Medicaid eligibility is determined. An MCO and PMP are selected with the assistance of the enrollment broker during the enrollment process when presumptive eligibility is established by a certified Qualified Provider. Also known as presumptive eligibility (PE).

Qualified Working Disabled (QWD)-See QDWI. A special program authorized by the Social Security Administration that allows individuals to work and still collect their disability payments for a period of time. The FSSA allows these individuals to remain on Medicaid while in QWD status.

Quality Assurance Reform Initiative (QARI)-Guidelines established by the federal government for quality assurance in Medicaid managed-care plans.

quality assurance/quality control (QA/QC)-Interrelated methods of monitoring the services that managed-care organizations (MCOs) arrange or administer for their enrollees.

A State-requested review of the fiscal agent's internal operations.

quality improvement (QI)-A continuous process that identifies problems in healthcare delivery, tests solutions to those problems, and constantly monitors the solutions for improvement.

Quality Improvement Committee (QIC)-The committee established by the Office of Medicaid Polity and Planning (OMPP) that provides oversight for the appropriateness and quality of care provided to enrollees by establishing standards and guidelines for the provision of care. The QIC is responsible for integrating the quality improvement process and services as a coordinating and advisory body.

quality initiative-A formal effort by an organization to improve the its products and services; usually top management develops a mission statement and long-term strategy.

quarter-Calendar quarter unless otherwise specified.

quarterly assessment-Minimum data set (MDS) assessment containing sections A-R is completed no less frequently than once every 90 days between annual full assessments.

query-An inquiry for specific information not supplied on standardized reports

QWD (qualified working disabled)-See QDWI. A special program authorized by the Social Security Administration that allows individuals to work and still collect their disability payments for a period of time. The FSSA allows these individuals to remain on Medicaid while in QWD status.

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R/A (Remittance and Status Report)-Computer data generated weekly to inform providers about the status of finalized and pending claims. The R/A includes explanation of benefit (EOB) codes that detail claim cutbacks and denials. When claims are paid, the provider receives a check enclosed in the R/A.

RA (Remittance Advice)-A weekly summary of provider reimbursement. RAs are sent to providers with checks or electronic funds transfers (EFTs) and provide information about claims that are paid, denied, in process, or adjusted, as well as information about other financial transactions. RAs are generated in accordance with providers' RA media type indicator. Only providers sending the majority of their claims electronically are allowed a choice of media. Formerly known as the explanation of payment (EOP). Plural: Remittance advices.

Railroad Retirement Board (RRB)-A separate insurance program that covers some aged people who would otherwise be covered by Medicare.

RAPs (resident assessment protocols)-A framework for organizing minimum data set (MDS) information and explaining additional relevant facts about an individual. RAPs help identify social, medical, and psychological problems and form the basis for individualized care planning.

rate-setting contractor-Entities under contract with the Office of Medicaid Policy and Planning (OMPP) to perform rate-setting activities for hospitals and long-term care facilities.

RBMC (risk-based managed care)-One of three delivery systems in the Hoosier Healthwise managed-care program, RBMC is a care delivery system in which the Office of Medicaid Policy and Planning (OMPP) pays contracted managed-care organizations (MCOs) a capitated monthly premium for each IHCP enrollee in the MCO's network. Members' care is managed through the MCO's network of primary medical providers (PMPs), specialists, and other healthcare providers that contract directly with the MCO. The delivery system serves pregnant women, children, and recipients of Temporary Assistance for Needy Families (TANF).

RBRVS (resource-based relative value scale)-A reimbursement method used to calculate payment for physicians, dentists, and other practitioners.

RCP (Restricted Card Program)-A program coordinated by the care-management organization that restricts the eligibility of members who have abused or overused services. Members remain eligible to receive all medically necessary, covered services allowed by the IHCP, but services are reimbursed only when rendered by one of the providers to whom the member is "locked in" or "restricted"; or by a specialist with a written referral from the primary lock-in physician.

reasonable charge-Charge for healthcare services rendered that is consistent with efficiency, economy, and quality of the care provided, as determined by the Office of Medicaid Policy and Planning (OMPP). (Under Medicare Part B, the lesser of the prevailing charge, billed amount, or customary charge.)

reasonable cost-All charges necessary in the efficient delivery of needed health services. Reasonable cost is the normal payment method for Medicare Part A.

recidivism-The frequency with which the same patient returns to a provider with the same presenting problems. Usually refers to inpatient hospital services.

recipient-An eligible person who receives medical services under the Medicaid program. This term is no longer used. See beneficiary, member.

recipient identification (RID) number, member identification number-The unique code assigned to an individual who is eligible for medical assistance programs.

recommendation for discharge-Assessing a resident, his or her capabilities, and outside available resources to determine whether he or she is ready to leave a healthcare facility. Based on 405 IAC1-3-1 and IAC1-3-2 criteria.

record-A set of related fields used to enter and store information in the telephone system. A table is a set of records.

record type-An alpha character representing one of many different types of assessment records. The MDS 2.0 record type is based on the reason for assessment codes in items AA8a and AA8b.

recoupment-Money withheld from a provider's payment due to overpayment of claims during adjudication. Recoupments may be established online by accessing the Accounts Receivable Set Up window. They may be percentages or set amounts. An account receivable record is established for each type of recoupment a provider has.

recovery site-The location of HP computer hardware and networking services used to recover application software and data after a disaster. Also called an alternate processing site.

Red Book-List of the average wholesale drug prices.

The publication by Thomson Reuters that is used as a reference in pricing drug products.

reference change category (CR)-A change (data value) that affects a system but does not require a technical (computer) resource.

referring provider-Healthcare professional who refers a member to another healthcare professional for treatment.

region-Sections of Indiana divided for managed-care purposes. Prior to 2007, there were three regions (North, Central, South). Beginning in 2007 there were eight regions (Northwest, North Central, Northeast, West Central, Central, East Central, Southwest, and Southeast).

Registered pharmacist (RPh)-Includes B.S. and Pharm.D. practitioners licensed by the state.

regulation-Federal or state rule designed and adopted to implement or interpret a law, policy, or procedure.

rehabilitation therapies-Services designed to improve the skills and adjustment of an individual with head injuries. Therapies integrate prevocational, educational, and independent living goals, so individuals can return to or maintain optimum levels of functioning at the least restrictive levels of care. Includes occupational therapy, physical therapy, speech-language therapy, cognitive therapy, behavioral therapies, and drug and alcohol abuse counseling.

reimbursement-Payment to a provider, pursuant to federal and State law, as compensation for providing covered services to members.

reinsurance-Insurance purchased by a health maintenance organization (HMO), insurance company, or self-funded employer from another insurance company to protect itself against all or part of the losses that may be incurred by honoring the claims of its participating providers, policyholders, or employees.

rejected claim-A claim that contains errors such as missing data, incorrect claim form, claims for noncovered services, ineligible provider or patient, duplicate claims, or missing provider signature. Rejected claims are returned to providers for correction and resubmission without being adjudicated.

related condition-Disability (other than mental retardation) that manifests before age 22 and results in substantial limitations in three of six major life activities - for example, self-care, expressive/receptive language, learning, mobility, self-direction, and capacity for independent living. These disabilities, which may include cerebral palsy, epilepsy, spina bifida, head injuries, and other diagnoses, may be related to mental retardation in how they affect individuals.

relative value system or scale (RVS)-A coding structure for all medical procedures that is based on the most commonly used procedure. The system assigns relative values to procedures, according to their degrees of difficulty.

A fee schedule which uses unit values (multiplied times a dollar conversion factor) to price procedures instead of using a flat fee. For example, a limited office visit might be valued at five units, and an extended office visit, which is more complex, at eight units. RVS fee schedules are easier to revise because it is not necessary to change the units, only the conversion factors, which are carried as system parameters in the Medicaid Management Information System (MMIS).

release-A specific version of a product made available to a client. Also known as system release or version.

Remittance Advice (RA)-A weekly summary of provider reimbursement. RAs are sent to providers with checks or electronic funds transfers (EFTs) and provide information about claims that are paid, denied, in process, or adjusted, as well as information about other financial transactions. RAs are generated in accordance with providers' RA media type indicator. Only providers sending the majority of their claims electronically are allowed a choice of media. Formerly known as the explanation of payment (EOP). Plural: Remittance advices.

Remittance and Status Report (R/A)-Computer data generated weekly to inform providers about the status of finalized and pending claims. The R/A includes explanation of benefit (EOB) codes that detail claim cutbacks and denials. When claims are paid, the provider receives a check enclosed in the R/A.

remitter-The name appearing on the check received.

rendering provider-A healthcare professional employed by a clinic or physician group who provides service as an employee. The employee is compensated by the group, and therefore does not bill Medicaid directly.

repayment receivables-Transaction established in the cash control system when a provider has received payment to which that provider was not entitled.

replacement-Modification to a previous claim. A Health Insurance Portability and Accountability Act (HIPAA) term for adjustment. May be electronic or paper.

report-Summary information used in business analysis.

request for proposal (RFP)-A bidding mechanism used to purchase goods and services.

requester-Person responsible for following up on issues to ensure that they are being worked. A requester must complete an Issue Request Form and review it with the leader and team member of the issue management system (IMS) workgroup before entering it in IMS.

requester (CR)-Individual writing a change request.

required field-Screen area that must be filled to display or update desired information. Sometimes designated by an asterisk (*).

resident assessment protocols (RAPs)-A framework for organizing minimum data set (MDS) information and explaining additional relevant facts about an individual. RAPs help identify social, medical, and psychological problems and form the basis for individualized care planning.

resident roster -Case Mix Roster/Time Weighted Report. A report generated from the Indiana MDS 2.0 system listing the latest record for each resident in a facility. This report may be for a specific day or for a period of time (for example, for a quarter). Myers and Stauffer provides these rosters to the HP Long-Term Care (LTC) Unit in audit packets.

resolution-Correcting errors on a claim, forcing edits, updating or modifying inaccurate data (such as provider number or category of service), or any other activity necessary to complete the adjudication of the claim. Usually seen as claims resolution, pending resolution, or suspense resolution.

resolutions-The area within the processing unit responsible for edit and audit correction.

Resource Utilization Group (RUG)-A classification system that identifies the relative costs (resource cost) of providing care for different types of residents in nursing facilities, based on residents' use of resources.

resource-based relative value scale (RBRVS)-A reimbursement method used to calculate payment for physicians, dentists, and other practitioners.

response code-Indicates who is responsible for the recovery action on a third-party liability (TPL) tracking case.

response to operational problems (RTOP)-The official HP mechanism for reporting problems that affect the client. In the case of a potential or actual disaster situation, the local Crisis Management Team uses RTOP to initiate and maintain a status report on the situation.

Restricted Card Program (RCP)-A program coordinated by the care-management organization that restricts the eligibility of members who have abused or overused services. Members remain eligible to receive all medically necessary, covered services allowed by the IHCP, but services are reimbursed only when rendered by one of the providers to whom the member is "locked in" or "restricted"; or by a specialist with a written referral from the primary lock-in physician.

retroactive recovery-A collection process, contracted to Health Management Systems (HMS), that is initiated after the IHCP has paid claims for members who are discovered to have other insurance, including commercial insurance and Medicare. This method is often referred to as pay-and-chase.

Retro-DUR (Retrospective Drug Utilization Review)-Reviewing claims to identify problems with drug prescribing or errors such as drug-to-drug interactions, overuse, drug-disease interactions, duplicate therapy, excessive or insufficient dosage, and drug pregnancy contraindications. In 1990, Congress required all state Medicaid agencies to implement DUR programs, of which Retro-DUR is one component, by 1993.

retro-rate adjustment-When a rate-setting agency changes a long-term care (LTC) facility's per diem rate, LTC and hospice claims that include long-term care services are automatically replaced or adjusted for the time period during which the rate was changed.

Retrospective Drug Utilization Review (Retro-DUR)-Reviewing claims to identify problems with drug prescribing or errors such as drug-to-drug interactions, overuse, drug-disease interactions, duplicate therapy, excessive or insufficient dosage, and drug pregnancy contraindications. In 1990, Congress required all state Medicaid agencies to implement DUR programs, of which Retro-DUR is one component, by 1993.

return to provider (RTP)-Request, in the form of a letter, for additional information from the healthcare professional.

revenue code-A three-digit numeral on hospital claims that corresponds to a specific accommodation or ancillary service billed on a UB-04, such as room and board (110), laboratory pathology (300), or physical therapy (420). Revenue codes are used in billing both inpatient and outpatient services and are essential to the hospital cost reporting process.

review date (CR)-The date a change request will be reviewed by the OMPP Operational Effectiveness Team (OET).

reviewed status (CR)-Status assigned to a change request when the OMPP Operational Effectiveness Team (OET) has reviewed it.

RFP (request for proposal)-A bidding mechanism used to purchase goods and services.

RHC (rural health clinic)-A cost-based reimbursement system of clinics created under the Rural Health Clinic Services Act of 1977. RHCs provide better access to services for people in rural, medically underserved areas through the use of mid-level practitioners.

RID (recipient identification) number; member identification number-The unique code assigned to an individual who is eligible for medical assistance programs.

risk analysis-Conducting an accurate and thorough assessment of potential vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (PHI).

risk contract-An agreement with a managed-care organization (MCO) to furnish services for enrollees for a determined, fixed payment. The MCO is liable for services regardless of the services' extent, expense, or degree.

risk pool or pool-An account defined by size, geographic location, claim dollars that exceed x level per individual, and so forth, to which revenue and expenses are posted. A risk pool attempts to define expected claim liabilities of a given account, as well as required funding to support the claim liability.

risk-based managed care (RBMC)-One of three delivery systems in the Hoosier Healthwise managed-care program, RBMC is a care delivery system in which the Office of Medicaid Policy and Planning (OMPP) pays contracted managed-care organizations (MCOs) a capitated monthly premium for each IHCP enrollee in the MCO's network. Members' care is managed through the MCO's network of primary medical providers (PMPs), specialists, and other healthcare providers that contract directly with the MCO. The delivery system serves pregnant women, children, and recipients of Temporary Assistance for Needy Families (TANF).

root cause-The most basic reason for a defect or problem, which if eliminated, would prevent recurrence.

route-Transfer of a claim to a certain area for special handling and review.

routine-A regular course of procedure.

routine change requests-A request for changes that are made on a regular basis - for example, annual Healthcare Common Procedure Coding System (HCPCS) updates.

RPh (Registered pharmacist)-Includes B.S. and Pharm.D. practitioners licensed by the state.

RRB (Railroad Retirement Board)-A separate insurance program that covers some aged people who would otherwise be covered by Medicare.

RTOP (response to operational problems)-The official HP mechanism for reporting problems that affect the client. In the case of a potential or actual disaster situation, the local Crisis Management Team uses RTOP to initiate and maintain a status report on the situation.

RTP (return to provider)-Request, in the form of a letter, for additional information from the healthcare professional.

RUG (Resource Utilization Group)-A classification system that identifies the relative costs (resource cost) of providing care for different types of residents in nursing facilities, based on residents' use of resources.

RUG-III-Version Three (III) of the Resource Utilization Group. All Medicare records are classified using RUG Grouper version 5.12 and all IHCP records are classified using RUG Grouper version 5.01.

RUG-III classification code-A classification system that identifies the relative costs (resource cost) of providing care for different types of residents in nursing facilities, based on residents' use of resources.

rural health clinic (RHC)-A cost-based reimbursement system of clinics created under the Rural Health Clinic Services Act of 1977. RHCs provide better access to services for people in rural, medically underserved areas through the use of mid-level practitioners.

RVS (relative value system or scale)-A coding structure for all medical procedures that is based on the most commonly used procedure. The system assigns relative values to procedures, according to their degrees of difficulty.

Rx-prescription.

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SA (State Survey Agency, Survey Agency)-The organization responsible for surveying, monitoring, reviewing, and certifying institutional service providers that request or agree to participate in the IHCP. In Indiana, this organization is the Indiana State Department of Health (ISDH).

SBOH (State Board of Health)-Previous term for the State Department of Health.

scan-To convert human-readable images into bitmapped or ASCII machine-readable code.

scheduled drugs / controlled drugs-Drugs, such as narcotics, sedative, hypnotics, and stimulants that have a high potential for abuse. There are five schedules, with Schedule I drugs being the most dangerous.

SCHIP (State Children's Health Insurance Program)-Title XXI of the Balanced Budget Act of 1997 created a new children's health insurance program called SCHIP. This program gave each state permission to offer health insurance for children up to age 19 who are not already insured. SCHIP is a state-administered program, and each state sets its own guidelines regarding eligibility and services.

scoring value (CR)-Value given to a change request based on metric assigned to section 3, 4, 6a-b and 7a.

screening-Quick, simple procedures carried out among large groups of people to sort out apparently well persons from those who have a disease or abnormality; and to identify those in need of more definitive examination or treatment.

SDX (State Data Exchange System)-The Social Security Administration's (SSA's) method of transferring SSA entitlement information to the State.

security coordinator-HP contact responsible for ensuring the Security Rule is fully implemented. Includes activities such as monitoring access reports, training employees, managing security violations, and applying sanctions.

SED (Serious Emotional Disturbance) waiver program-A Home- and Community-Based Services (HCBS) classification for beneficiaries under the age of 18 who are diagnosed with severe mental illness.

selective contracting-Option under Section 1915(b) of the Social Security Act that allows a state to develop a competitive contracting system for services such as inpatient hospital care.

Serious Emotional Disturbance (SED) waiver program-A Home- and Community-Based Services (HCBS) classification for beneficiaries under the age of 18 who are diagnosed with severe mental illness.

service-A healthcare procedure, test, treatment, drug prescription, diagnosis, screening, and so on, that providers perform for beneficiaries and that may be covered under Medicaid. Usually indicated by a procedure or drug code, which is adjudicated separately from other services.

service date or date of service-Day of the month and year on which a healthcare professional provides service to a member.

service level-The percentage of calls that are answered within a period of time.

service limits-Maximum number of service units to which a member is entitled, as established by the IHCP for a particular category of service. For example, the number of inpatient hospital days covered by the IHCP might be limited to no more than 30.

severity level-The relative importance of a change order, as defined by the Office of Medicaid Policy and Planning (OMPP). Severity levels range from one to five, with one being the most critical.

shadow claims-See encounter claims.

significant change-A major shift in a resident's status that is not self-limiting, affects more than one area of resident's health, or requires interdisciplinary review or revision of the resident's care plan.

SKEY (Smart Key)-The SKEY is a series of eight data elements that lets users classify products. The elements can be used together or independently to define and maintain formularies, create bid lists, and summarize data. The eight subfields of the SKEY are:

Generic Therapeutic Class (GTC) - Length (2)
Specific Therapeutic Class (GC3) - Length (4)
HICL Sequence Number (HICL_SEQNO) - Length (5)
Strength Code (STR) - Length (4)
Dosage Form Code (DOSE) - Length (2)
Route Code (RT) - Length (2)
Package Size (PS) - Length (3)
Unit-Dose/Unit-of-Use (UDUU) - Length (1)

skilled nursing facility (SNF)-An institution that provides room, board, and all routine services and supplies, including qualified professionals that remain on site 24 hours a day. SNFs must be licensed by the State.

SLIMB or SLMB (specified low-income Medicare beneficiary)-A federal category defining Medicaid eligibility for aged, blind, or disabled individuals with incomes between 100 and 120 percent of the federal poverty level and who have assets less than twice the supplementary security income (SSI) asset level. Medicaid benefits include payment of the Medicare Part B premium only.

SMAC (State maximum allowable cost)-The method used by the State to determine the maximum payment for drugs. Also known as State MAC.

Smart Key (SKEY)-A series of eight data elements that lets users classify products. The elements can be used together or independently to define and maintain formularies, create bid lists, and summarize data. The eight subfields of the SKEY are:

Generic Therapeutic Class (GTC) - Length (2)
Specific Therapeutic Class (GC3) - Length (4)
HICL Sequence Number (HICL_SEQNO) - Length (5)
Strength Code (STR) - Length (4)
Dosage Form Code (DOSE) - Length (2)
Route Code (RT) - Length (2)
Package Size (PS) - Length (3)
Unit-Dose/Unit-of-Use (UDUU) - Length (1)

SME (subject-matter expert)-An individual who exhibits the highest level of expertise in performing a specialized job, task, or skill within an organization; the person assigned to take the lead on determining reasons for issues and identifying and implementing solutions. The SME becomes the contact for information in his or her area of specialty.

SMI (supplemental medical insurance)-Medicare Part B or the portion of Medicare financed by enrollees' monthly premiums and a matching federal amount. All persons entitled to Medicare Part A are eligible.

SNF (skilled nursing facility)-An institution that provides room, board, and all routine services and supplies, including qualified professionals that remain on site 24 hours a day. SNFs must be licensed by the State.

SNIP (Strategic National Implementation Process)-A Workshop for Electronic Data Interchange (WEDI) program that helps the healthcare industry identify and resolve implementation issues connected with the Healthcare Insurance Portability and Accountability Act (HIPAA).

Social Security Administration (SSA)-Branch of the Department of Health and Human Services which administers the Medicare and Medicaid Programs.

Social Security claim number (SSCN)-Account code used by SSA to identify the individual on whose earnings SSA benefits are being paid. Followed by a suffix, it is sometimes as many as three characters, designating the type of beneficiary (for example, wife, widow, child, and so forth). The SSCN must be used in the Buy-In program. A beneficiary can have his or her own SSN but be receiving benefits under a different claim number.

Social Security number (SSN)-The number used by the SSA throughout a wage earner's lifetime to identify eligible earnings under the Social Security Program. This account number consists of nine figures divided into three hyphenated sets, 000-00-0000. This number is not to be confused with SSCN.

Social Security, Social Security Act or Social Security Act of 1935 (SS, SSA)-A government program that provides economic assistance to persons faced with unemployment, disability, or agedness, financed by assessing employers and employees. Established by the Social Security Act (August 14, 1935).

sole proprietorship (NPI)-A business in which one person owns all assets and is solely liable for all debts. Sole proprietors are individuals and must apply for their National Provider Identifiers (NPIs) as Individuals (Entity Type I). If an individual owns three separate organizations with unique tax ID numbers, each would be eligible for a unique NPI.

Southeast Region-An enrollment area in Southeast Indiana that includes the following counties: Bartholomew, Clark, Crawford, Dearborn, Decatur, Floyd, Franklin, Harrison, Jackson, Jefferson, Jennings, Ohio, Ripley, Scott, Switzerland, and Washington. The enrollment area for Hoosier Healthwise - RBMC was effective January 2007; for Care Select, March 2008.

Southwest Region-An enrollment area in Southwest Indiana that includes the following counties: Brown, Daviess, Dubois, Gibson, Greene, Knox, Lawrence, Martin, Monroe, Ohio, Orange, Owen, Perry, Pike, Posey, Spencer, Vanderburgh, and Warrick. The enrollment area for Hoosier Healthwise - RBMC was effective January 2007; for Care Select, March 2008.

span-dates-A period for which services were rendered to a member by a provider (the first and last dates of service are not the same days).

special services-Treatment available to children under age 21 not otherwise covered by the Medicaid State Plan. Services must be deemed necessary as a result of a health screen through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

special vendors-Businesses that provide support to IHCP functions but are not Medicaid fiscal agents.

specialty-specialized practice area of a provider.

specialty certification-Certification or approval by a professional academy, association, or society that affirms a provider has demonstrated a given level of training or competence and is a fellow or specialist.

specialty vendors-Businesses that provide support to IHCP functions but are not IHCP fiscal agents.

specified low-income Medicare beneficiary (SLMB or SLIMB)-A federal category defining Medicaid eligibility for aged, blind, or disabled individuals with incomes between 100 and 120 percent of the federal poverty level and who have assets less than twice the supplementary security income (SSI) asset level. Medicaid benefits include payment of the Medicare Part B premium only.

spend-down-A type of Medicaid insurance deductible that allows people whose income is more than the standard to receive some Medicaid reimbursement. To be eligible, these beneficiaries must pay some of their medical bills themselves (spend-down) to offset their excess income. Spend-down is the difference between the beneficiary's income and the Medicaid income limit. A qualifying caseworker or the enrollment center/document center may assign this dollar amount to a beneficiary (based on the beneficiary's income, and so forth.), which must be spent on medical needs before Medicaid benefits are available.

SPR (System Performance Review)-A review by the Centers for Medicare & Medicaid Services (CMS) to improve effectiveness and efficiency by assuring that claims processing and information retrieval systems meet minimum operational performance standards.

SS (Support Services) waiver-Programs (such as public assistance, medical assistance, food stamps, and so forth) that seek to improve the quality of life for individuals and families.

SS, SSA (Social Security, Social Security Act or Social Security Act of 1935)-A government program that provides economic assistance to persons faced with unemployment, disability, or agedness, financed by assessing employers and employees. Established by the Social Security Act (August 14, 1935).

SSA (Social Security Administration)-Branch of the Department of Health and Human Services which administers the Medicare and Medicaid Programs.

SSA, SS (Social Security Act or Social Security Act of 1935; Social Security)-A government program that provides economic assistance to persons faced with unemployment, disability, or agedness, financed by assessing employers and employees. Established by the Social Security Act (August 14, 1935).

SSCN (Social Security claim number)-Account code used by SSA to identify the individual on whose earnings SSA benefits are being paid. Followed by a suffix, it is sometimes as many as three characters, designating the type of beneficiary (for example, wife, widow, child, and so forth). The SSCN must be used in the Buy-In program. A beneficiary can have his or her own SSN but be receiving benefits under a different claim number.

SSI (Supplementary Security Income)-A financial support program administered by the Social Security Administration that provides federal cash assistance to low-income aged, blind, and disabled individuals to help them pay their living expenses.

SSN (Social Security number)-The number used by the SSA throughout a wage earner's lifetime to identify eligible earnings under the Social Security Program. This account number consists of nine figures divided into three hyphenated sets, 000-00-0000. This number is not to be confused with SSCN.

SSP (State Supplement Program)-State-funded program providing cash assistance to supplement the income of aged, blind, and disabled individuals who receive Supplementary Security Income (SSI) or who, except for income or other criteria, would be eligible for SSI.

staff model HMO-Healthcare model that employs physicians to provide healthcare to its members. All premiums and other revenues accrue to the health maintenance organization (HMO), which compensates physicians by salary and incentive programs.

standard business-Healthcare company within the private sector of the industry, such as Blue Cross and Blue Shield.

State-Spelled as shown, State refers to the state of Indiana and any of its departments or agencies.

State Board of Health (SBOH)-Previous term for the State Department of Health.

State Children's Health Insurance Program (SCHIP)-Title XXI of the Balanced Budget Act of 1997 created a new children's health insurance program called SCHIP. This program gave each state permission to offer health insurance for children up to age 19 who are not already insured. SCHIP is a state-administered program, and each state sets its own guidelines regarding eligibility and services.

State Data Exchange System (SDX)-The Social Security Administration's (SSA's) method of transferring SSA entitlement information to the State.

State fiscal year-A 12-month period beginning July 1 and ending June 30.

State Form 11971-DPW Form 8A (State Form 11971), Notice to Provider of Member Deductible.

State Form 44697-State Form 44697, OMPP (Division of Family and Children State Form) 1261A, Certification - Plan of Care for Inpatient Psychiatric Hospital Services Determination of Medicaid Eligibility. Used to provide written certification of need for inpatient psychiatric admissions. Hospitals must submit this form to Medicaid's medical policy contractor for admissions to private psychiatric hospitals. State-owned psychiatric facilities must submit this form to the MMRT. The form is reviewed by the Medicaid policy contractor or the MMRT to determine appropriateness of the inpatient stay.

State Form 7748-Medicaid Financial Report used for cost reporting.

State MAC (State maximum allowable cost)-The method used by the State to determine the maximum payment for drugs. Also known as SMAC.

State Maximum Allowable Cost (SMAC)-The method used by the State to determine the maximum payment for drugs. Also known as State MAC.

State Medicaid Office-The Office of Medicaid Policy and Planning (OMPP) within the Family and Social Services Administration (FSSA), which is responsible for administering the IHCP in Indiana.

State Plan-The medical assistance plan of Indiana, as approved by the Secretary of Health, Education, and Welfare in accordance with provisions of Title XIX of the Social Security Act.

State Supplement Program (SSP)-State-funded program providing cash assistance to supplement the income of aged, blind, and disabled individuals who receive Supplementary Security Income (SSI) or who, except for income or other criteria, would be eligible for SSI.

State Survey Agency, Survey Agency (State SA, SA)-The organization responsible for surveying, monitoring, reviewing, and certifying institutional service providers that request or agree to participate in the IHCP. In Indiana, this organization is the Indiana State Department of Health (ISDH).

status-Condition of a claim at a given time, such as paid, pended, suspended, or denied.

Step Therapy Group (STG)-Beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and progressing to other more costly or risky therapies, if necessary. The aims are to control costs and minimize risks. For example, a beneficiary might not be able to use a drug from level (B) without first going through the therapy for level (A).

Step Therapy Levels-The tiers of drugs used in Step Therapy. See STG.

sterile water products-Sterile water products are not separately reimbursable in a nursing facility (NF) benefit plan, because they are reimbursed under the facility's per diem rate. If the sterile water product is part of a compound, it is reimbursable. Sterile water products include sterile water for injection and sterile wate for irrigation. Sterile water products are identified with a Specific Therapeutic Class = "W8F."

STG (Step Therapy Group)-Beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and progressing to other more costly or risky therapies, if necessary. The aims are to control costs and minimize risks. For example, a beneficiary might not be able to use a drug from level (B) without first going through the therapy for level (A).

stop-loss-If a claim exceeds a predetermined cap, a stop-loss clause in a contract protects managed care providers from catastrophic losses. For example, if a health maintenance organization (HMO) refers a beneficiary to a specialist whose fee ends up being greater than the stop-loss amount, and the HMO contract provides for stop-loss, the excess cost will be paid at the percentage (70 percent or 90 percent) contained on the Plan File for this plan and service class. Primary care provider/case manager (PCP/CM) claims are paid at 100 percent when the cap is reached.

stop-loss insurance-Coverage taken out by a health plan or self-funded employer to provide protection from losses resulting from claims greater than a specific dollar amount per covered person per year (calendar year or illness to illness). Types of stop-loss insurance reimbursements include:

Specific or individual reimbursement - for claims on any covered individual that exceed a predetermined deductible.

Aggregate reimbursement - for total claims that exceed a predetermined level, such as 125 percent of the amount expected in an average year.

Strategic National Implementation Process (SNIP)-A Workshop for Electronic Data Interchange (WEDI) program that helps the healthcare industry identify and resolve implementation issues connected with the Healthcare Insurance Portability and Accountability Act (HIPAA).

strong password-A password that is at least eight characters in length and that contains three of the four groups below:

Numbers
Uppercase letter
Lowercase letter
Special characters, defined as ! # $ % & ' ( ) * + , - . / : < = > ? [ ] ^ _ ` { | }

At minimum, a strong password must be different from the previous seven passwords and must not contain the user ID, first name, or last name.

subcontractor-Any person or firm performing part of the work defined under the terms of a contract, by virtue of an agreement with the prime contractor. Before the subcontractor begins, the prime contractor must receive written consent and approval of the State.

subject-matter expert (SME)-An individual who exhibits the highest level of expertise in performing a specialized job, task, or skill within an organization; the person assigned to take the lead on determining reasons for issues and identifying and implementing solutions. The SME becomes the contact for information in his or her area of specialty.

submission-Sending billings to HP for payment.

subparts-Components or separate physical locations of healthcare providers that are organizations, such as hospitals, pharmacies, nursing homes, supplier groups, home health agencies, ambulatory surgical centers, ambulance companies, durable medical equipment (DME) suppliers, and so on.

Some provider organizations may be able to obtain more than one National Provider Identifier (NPI) to be identified in separate transactions. The following are examples of subparts:

Certified separately.
Licensed separately by the State.
Federal regulations requiring a personal billing number.

Subparts do not apply to individual providers.

subsystem-A Medicaid term that refers to one of the following Health Information System (HIS) or Intelligent Health Information System (IHIS) components: member, provider, claims processing, reference file, Surveillance and Utilization Review (SUR), and management and administrative reporting.

supplemental medical insurance (SMI)-Medicare Part B or the portion of Medicare financed by enrollees' monthly premiums and a matching federal amount. All persons entitled to Medicare Part A are eligible.

supplementary Security Income (SSI)-A financial support program administered by the Social Security Administration that provides federal cash assistance to low-income aged, blind, and disabled individuals to help them pay their living expenses.

Support Services (SS) waiver-Programs (such as public assistance, medical assistance, food stamps, and so forth) that seek to improve the quality of life for individuals and families.

SUR (Surveillance and Utilization Review)-Refers to activities mandated by the Centers for Medicare & Medicaid Services (CMS) to ensure complete compliance with regulatory requirements, including the following:

Statistical analysis.
Exception processing.
Provider and member profiles.
Retrospective detection of edit and audit failures and errors during claims processing.
Retrospective detection of payments and use that are inconsistent with State or federal policies and medical necessity.
Retrospective detection of fraud and abuse by providers or members.
Sophisticated data and claim analysis, including sampling and reporting.
General access and processing features.
General reports and output.

Surveillance and Utilization Review (SUR)-Refers to activities mandated by the Centers for Medicare & Medicaid Services (CMS) to ensure complete compliance with regulatory requirements, including the following:

Statistical analysis.
Exception processing.
Provider and member profiles.
Retrospective detection of edit and audit failures and errors during claims processing.
Retrospective detection of payments and use that are inconsistent with State or federal policies and medical necessity.
Retrospective detection of fraud and abuse by providers or members.
Sophisticated data and claim analysis, including sampling and reporting.
General access and processing features.
General reports and output.

Survey Agency, State Survey Agency (SA, State SA)-The organization responsible for surveying, monitoring, reviewing, and certifying institutional service providers that request or agree to participate in the IHCP. In Indiana, this organization is the Indiana State Department of Health (ISDH).

suspended claim-A claim that is being processed and has neither paid nor denied.

FSS claims that have been held during processing to allow a manual review of the claim. Encounter data does not suspend for any reason.

suspended transaction-A claim that requires further action before it is paid or denied. Most commonly, a transaction is suspended because of entry or compliance errors.

suspense file-Electronic file of transactions that cannot be processed. Most commonly, transaction are placed in the suspense file because of entry or compliance errors.

Sybase Translator-The software used by the IHCP for compliance checking and for translating EDI transactions.

system change category (CR)-Any modification to computer software applications, hardware, and firmware, such as an imaging system.

system generated-Information not originating from another source (such as data files, data transmissions, or user entries). Examples are date, time, calculated numbers, and so forth.

System Performance Review (SPR)-A review by the Centers for Medicare & Medicaid Services (CMS) to improve effectiveness and efficiency by assuring that claims processing and information retrieval systems meet minimum operational performance standards.

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tamper-resistant prescription pad (TRPP)-A handwritten or computer generated and printed prescription must contain at least one feature in all three categories. No feature may be used twice:

One or more industry recognized features designed to prevent unauthorized copying of a completed or blank prescription.
One or more industry recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber.
One or more industry recognized features designed to prevent the use of counterfeit prescriptions.

TANF (Temporary Assistance for Needy Families)-A welfare program funded by federal and State dollars that provides cash and Medicaid benefits to families with at least one child where one or both parents are absent, deceased, or incapacitated.

Tax Equity and Fiscal Responsibility Act of 1982, section 134 (a) [TEFRA 134(a)]-A provision of this federal law allows states the option of covering children with physical and mental disabilities in the community if the child would be eligible for Medicaid institutional services but can be cared for at home.

Tax ID (tax identification number)-Also known as TIN.

taxonomy code-Unique alphanumeric code, 10 characters in length, that communicates provider type, classification, and area of specialization.

TC (technical component)-The portion of a service that is considered nonphysician, such as tests and related equipment. This is indicated by the TC modifier when billed on a claim with a procedure code that includes both technical and professional components.

TDOS (termination date of service)-Last date of service.

TDOS (To Date of Service)-Date used in the claim

technical component (TC)-The portion of a service that is considered nonphysician, such as tests and related equipment. This is indicated by the TC modifier when billed on a claim with a procedure code that includes both technical and professional components.

TEFRA 134(a) [Tax Equity and Fiscal Responsibility Act of 1982, Section 134 (a)]-A provision of this federal law allows states the option of covering children with physical and mental disabilities in the community if the child would be eligible for Medicaid institutional services but can be cared for at home.

Temporary Assistance for Needy Families (TANF)-A welfare program funded by federal and State dollars that provides cash and Medicaid benefits to families with at least one child where one or both parents are absent, deceased, or incapacitated.

termination date of service (TDOS)-Last date of service.

The Johns Hopkins University ACG Case-Mix System-The industry standard for measuring morbidity by evaluating provider performance, forecasting healthcare use, and setting equitable payment rates. It measures the morbidity burden of patient populations based on disease patterns, age, and gender, and creates a common language for healthcare analysis that benefits providers, purchasers, and consumers of healthcare.

Therapeutic Class Code, Generic (GTC)-Therapeutic Class Code, Generic (GTC) classifies drugs according to their most common intended use. This classification provides the broadest therapeutic groupings available in the National Drug Data File (NDDF). Users that need more definitive therapeutic classing should consider Therapeutic Class, Standard (TC), Therapeutic Class, Specific (GC3), or the Therapeutic Class, AHFS (AHFS).

Therapeutic Class Code, Specific (GC3)-Therapeutic Class Code, Specific (GC3) is the most specific therapeutic class coding scheme offered by First DataBank and is intended for users who need a very definitive therapeutic classification system.

Therapeutic Class Code, Standard (TC)-Therapeutic Class Code, Standard (TC) can be used to classify drugs according to their most common intended use. This therapeutic classification is intended to serve users who need a definitive but not comprehensive therapeutic classification system.

Therapeutic Class, AHFS-Therapeutic Class, AHFS (AHFS) identifies the pharmacologic therapeutic category of the drug product according to the AHFS classification system.

therapeutic classification-Code assigned to a group of drugs that possess similar therapeutic qualities. Drugs are categorized according to their beneficial effects or ingredients. First DataBank offers three different therapeutic classifications systems. Therapeutic class is used as a selection criterion to group claims for different drugs that have the same effects, such as central nervous system depressants

third party-Any person or entity that is liable to pay for healthcare and services rendered to an IHCP enrollee. Examples of third parties include an individual or group plan health insurer, casualty insurer, a health maintenance organization, or an employer-administered ERISA plan.

third-party liability (TPL)-A member's medical payment resources, other than Medicaid. These resources may include applicable Medicare coverage, worker's compensation, and accident-related liability insurance through public and private insurance carriers. Identifying and pursuing these resources help Medicaid contain its program costs.

third-party recovery-A collection process, contracted to Health Management Systems, that is initiated after the IHCP has paid claims for members who are discovered to have other insurance. This method is often referred to as pay-and-chase.

third-party resource-An individual or company liable for payment of an IHCP member's medical bills.

TIN (tax identification number)-Also known as Tax ID

Title I-Social Security Act (August 14, 1935) [H. R. 7260], Title I. The Old Age Assistance Program that was replaced by the Supplemental Security Income program.

Title II-Social Security Act (August 14, 1935) [H. R. 7260], Title II - Old Age, Survivors and Disability Insurance Benefits (Social Security or OASDI).

Title III-Social Security Act (August 14, 1935) [H. R. 7260], Title III - Unemployment Benefits.

Title IV-The Aid to Families with Dependent Children program.

Title IV-A-Social Security Act (August 14, 1935) [H. R. 7260], Title IV-A - Aid to Families with Dependent Children, WIN Social Services.

Title IV-B-Social Security Act (August 14, 1935) [H. R. 7260], Title IV-B - Child Welfare.

Title IV-D-Social Security Act (August 14, 1935) [H. R. 7260], Title IV-D - Child Support.

Title IV-E-Social Security Act (August 14, 1935) [H. R. 7260], Title IV-E - Foster Care and Adoption. Provides federal funds for eligible children in foster care, administration of the foster care program, and training for workers and foster parents. Also subsidizes and supports children with special needs who are placed for adoption.

Title IV-F-Social Security Act (August 14, 1935) [H. R. 7260], Title IV-F - Job Opportunities and Basic Skills Training.

Title IX-Social Security Act (August 14, 1935) [H. R. 7260], Title IX - Miscellaneous Provisions Relating to Employment Security.

Title V-Social Security Act (August 14, 1935) [H. R. 7260], Title V - Maternal and Child Health Services. Includes the following:

Part 1 - Maternal and Child Health Services
Part2 - Services for Crippled Children
Part 3 - Child Welfare Services
Part 4 - Vocational Rehabilitation
Part 5 - Administration

Title VI-Social Security Act (August 14, 1935) [H. R. 7260], Title VI - Public Health Work.

Title VII-Social Security Act (August 14, 1935) [H. R. 7260], Title VII - Social Security Board.

Title VIII-Social Security Act (August 14, 1935) [H. R. 7260], Title VIII - Special Benefits for Certain World War II Veterans.

Title X-Social Security Act (August 14, 1935) [H. R. 7260], Title X - Aid to the Blind program. Replaced by the Supplemental Security Income program.

Title XI-Social Security Act (August 14, 1935) [H. R. 7260], Title XI - General Provisions, Peer Review, and Administrative Simplification.

Title XII-Social Security Act (August 14, 1935) [H. R. 7260], Title XII - Advances to State Unemployment Funds.

Title XIII-Social Security Act (August 14, 1935) [H. R. 7260], Title XIII - Reconversion Unemployment Benefits for Seamen. Repealed.

Title XIV-Social Security Act (August 14, 1935) [H. R. 7260], Title XIV - Permanently and Totally Disabled program. Replaced by the Supplemental Security Income program.

Title XIX-Social Security Act (August 14, 1935) [H. R. 7260], Title XIX - Provides grants to States for Medical Assistance Programs. See Medicaid.

Title XIX Hospital-Hospital participating under Medicare.

Title XV-Social Security Act (August 14, 1935) [H. R. 7260], Title XV - Unemployment Compensation for Federal Employees. Repealed.

Title XVI-Social Security Act (August 14, 1935) [H. R. 7260], Title XVI - Supplemental Security Income for the Aged, Blind, or Disabled.

Title XVII-Social Security Act (August 14, 1935) [H. R. 7260], Title XVII - Grants for Planning Comprehensive Action to Combat Mental Retardation.

Title XVIII-Social Security Act (August 14, 1935) [H. R. 7260], Title XVIII - Health Insurance for the Aged, Blind, and Disabled. The Medicare Health Insurance program covering hospitalization (Part A) and medical insurance (Part B).

Title XXI-Child Health Insurance Program as part of the Social Security Act. Provides medical benefits for beneficiaries under the age of 19 who are between 150 and 200 percent of poverty. Also referred to as SCHIP.

To Date of Service (TDOS)-Date used in the claim

TOB (type of bill)-Provides specific information about a bill for Medicare (or other payer's) billing purposes on institutional claims.

TPL (third-party liability)-A member's medical payment resources, other than Medicaid. These resources may include applicable Medicare coverage, worker's compensation, and accident-related liability insurance through public and private insurance carriers. Identifying and pursuing these resources help Medicaid contain its program costs.

TPL/Drug Rebate Services-Refers to Service Package #3 - Third-Party Liability and Drug Rebate Services.

trading partner-Any organization or individual that exchanges transaction data electronically with the IHCP.

trading partner agreement-An agreement between the IHCP and businesses or agencies that exchange data electronically.

Traditional Medicaid-In the beginning, Medicaid was a fee-for-service program, meaning that the government paid providers, such as doctors, clinics, and hospitals, for each of the services they provided with Medicaid. In most states, Medicaid has been shifting to a managed care system, in which the government pays a health plan a certain dollar amount for each Medicaid beneficiary enrolled and in return, the plan provides for most of the enrollee's care. This change was designed to help control Medicaid costs.

transaction-Under HIPAA, the exchange of information between two parties to carry out financial or administrative activities related to healthcare.

transaction set-A block of information in EDI that makes up a business exchange or part of a business exchange.

transaction set standards-The system of syntax, data elements, segments, and transaction sets (messages) with which business at EDI is conducted.

Transactions & Code Sets Rule (TCS Rule)-A rule that specifies that certain providers can be restricted to billing only certain procedure codes.

treatment-Any type of medical care and services recognized under state law to prevent, correct, or ameliorate disease or abnormalities detected by screening and diagnostic procedures.

trend-Measure of the rate at which a piece of data is changing.

TRICARE-A healthcare plan for active duty family members, military retirees, and family members of military retirees. Formerly known as CHAMPUS.

TrOOP (true out of pocket)-The amount the member pays out of pocket, including copay or deductibles that Medicaid pays.

TRPP (tamper-resistant prescription pad)-A handwritten or computer generated and printed prescription must contain at least one feature in all three categories. No feature may be used twice:

One or more industry recognized features designed to prevent unauthorized copying of a completed or blank prescription.
One or more industry recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber.
One or more industry recognized features designed to prevent the use of counterfeit prescriptions.

true out of pocket (TrOOP)-The amount the member pays out of pocket, including copay or deductibles that Medicaid pays.

type of bill (TOB)-Provides specific information about a bill for Medicare (or other payer's) billing purposes on institutional claims.

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U.S. Department of Health and Human Services-Umbrella agency for the Office of Family Assistance, the CMS, the Office of Refugee Resettlement, and other federal agencies serving health and human service needs. Also known as DHHS, DHS, and HHS.

UB-04 (Uniform billing form 04)-The standard claim form used to bill hospital inpatient and outpatient, nursing facility, intermediate care facilities for the mentally retarded, and hospice services. This form replaces UB-92. Electronic claims are submitted using the 837 I transaction, and include fields for NPIs. UB-04 is also known as an institutional claim form.

UB-92 (Uniform billing form 92)-Formerly, the standard claim form used to bill hospital inpatient and outpatient, nursing facility, intermediate care facility for the mentally retarded, and hospice services. This form was replaced by UB-04 in 2007.

UCR (usual, customary, and reasonable)-Charges most commonly billed for a service by a provider; the price the provider charges his patients for a service.

A method of calculating charges based on previously billed charges.

UM (utilization management)-Reviewing and managing the use of services in a cooperative effort with other parties, including patients, employers, providers, and payers.

A unit of the fiscal agent that promotes cost-effective, quality healthcare through research, thorough reviews, and networks with agencies and committees.

Uniform billing form 04 (UB-04)-The standard claim form used to bill hospital inpatient and outpatient, nursing facility, intermediate care facilities for the mentally retarded, and hospice services. This form replaces UB-92. Electronic claims are submitted using the 837 I transaction, and include fields for NPIs. UB-04 is also known as an institutional claim form.

Uniform billing form 92 (UB-92)-Formerly, the standard claim form used to bill hospital inpatient and outpatient, nursing facility, intermediate care facility for the mentally retarded, and hospice services. This form was replaced by UB-04 in 2007.

unit dose-Drugs that are individually packaged. Used mainly in nursing home and hospital environments.

unit of service-Measurement divisions for a particular service, such as one hour, one-quarter hour, an assessment, a day, and so forth.

Universal Product Code (UPC)-Codes contained on the first data bank tape update or applied to products, such as drugs and other pharmaceutical products.

universe-A logical grouping of like subject matter such as claim, provider, or member data.

unlisted procedure-Services or procedures performed by physicians that are not identified in the Common Procedural Terminology code book with specific procedure codes. Unlisted procedure codes often end in a '99' and may require additional information about the procedure to determine pricing and medical necessity.

UPC (Universal Product Code)-Codes contained on the first data bank tape update or applied to products, such as drugs and other pharmaceutical products.

UR (utilization review)-A formal assessment of the medical necessity, efficiency, or appropriateness of healthcare services and treatment plans on a prospective, concurrent, or retrospective basis.

urgent-A condition not likely to cause death or lasting harm, but for which treatment should not wait for the next day or for a scheduled appointment.

user-data processing system customer or client.

User ID-The unique code that allows an individual to sign onto a computer system and defines his or her security status.

usual, customary, and reasonable (UCR)-Charges most commonly billed for a service by a provider; the price the provider charges his patients for a service.

A method of calculating charges based on previously billed charges.

utilization-The extent to which members of a covered group use a program or obtain a service or category of procedures over a given period of time. Usually expressed as the number of services used per year or per numbers of persons eligible for the services.

utilization guidelines-The regulatory term for instructions concerning when and how to use the Resident Assessment Instrument.

utilization management (UM)-Reviewing and managing the use of services in a cooperative effort with other parties, including patients, employers, providers, and payers.

A unit of the fiscal agent that promotes cost-effective, quality healthcare through research, thorough reviews, and networks with agencies and committees.

utilization review (UR)-A formal assessment of the medical necessity, efficiency, or appropriateness of healthcare services and treatment plans on a prospective, concurrent, or retrospective basis.

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Vaccines for Children (VCF)-Federally funded program that provides immunizations for qualified children.

Validation Report-An electronic file that contains detailed information about minimum data set assessments transmitted. Validation files are in a provider's download directory.

value code-Used on UB-04 forms to indicate the related dollar amount required for processing claims.

value-added network (VAN)-A vendor of EDI data communications and translation services. (Switched network provider)

VAN (value-added network)-A vendor of EDI data communications and translation services. (Switched network provider)

vendor-An institution, agency, organization, or an individual practitioner who provides healthcare services.

VFC (Vaccines for Children)-Federally funded program that provides immunizations for qualified children.

voice response system (VRS)-See AVR, Automated Voice Response system.

void-cancellation of a claim (electronic or paper submission).

VRS (voice response system)-See AVR, Automated Voice Response system.

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waiver-A program that allows members to move from Traditional Medicaid to less-restrictive environments, letting states customize specific rules and regulations to their medical assistance programs for more cost-effective services.

waiver provider-A healthcare professional enrolled in the Waiver Program with an open waiver Level of Care status. Enables individuals to receive qualifying services in their homes and community settings.

walkthrough schedule and summary report (WSSR)-A formal review in which a developer leads one or more members of a project team through requirements, design specifications, or other output. The members ask questions and make comments about possible errors, violations of published standards, and other problems. The purpose of the review is to ensure that the output meets published standards and project requirements.

warrant-An order for payment/reimbursement. After adjudication, a claim is marked for payment or denial. If one is marked for payment, a warrant is issued for the State finance to issue a check.

warrant number-The actual check number issued for claims payments to providers.

warrant type-The type of warrant that is issued to Medicaid providers, whether a value of E (electronic funds transfer) or P (paper).

Washington Publishing Company (WPC)-WPC. The company that publishes the X12N HIPAA Implementation Guides and the X12N HIPAA Data Dictionary; WPC also developed the X12 Data Dictionary and hosts the EHNAC STFCS testing program.

Web interChange-A secure Internet site offered by HP that allows providers to inquire about IHCP claim information, submit electronic claims, verify eligibility, and maintain provider information.

WEDI (Workgroup for Electronic Data Interchange)-A healthcare industry group that lobbied for HIPAA Administrative Simplification (A/S) and that has a formal consultative role under the HIPAA legislation. WEDI also sponsors SNIP.

West Central Region-A Hoosier Healthwise enrollment area in West Central Indiana that includes the following counties: Benton, Carroll, Clay, Clinton, Fountain, Montgomery, Parke, Sullivan, Tippecanoe, Vermillion, Vigo, Warren, and White. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007; for Care Select, March 1, 2008.

Women, Infants, and Children Program (WIC)-WIC. A federal program administered by the Indiana State Department of Health that provides nutritional supplements to low-income pregnant or breastfeeding women and to infants and children younger than five years old.

workers' compensation-A type of third-party liability for medical services rendered as the result of on-the-job accidents or injuries for which an employer's insurance company may be obligated under the Workers' Compensation Act. Formerly known as workmen's compensation.

Workgroup for Electronic Data Interchange (WEDI)-A healthcare industry group that lobbied for HIPAA Administrative Simplification (A/S) and that has a formal consultative role under the HIPAA legislation. WEDI also sponsors SNIP.

WPC (Washington Publishing Company)-WPC. The company that publishes the X12N HIPAA Implementation Guides and the X12N HIPAA Data Dictionary; WPC also developed the X12 Data Dictionary and hosts the EHNAC STFCS testing program.

write-offs-One-time financial transactions that clear accounts receivable of negative balances.

WSSR (walkthrough schedule and summary report)-A formal review in which a developer leads one or more members of a project team through requirements, design specifications, or other output. The members ask questions and make comments about possible errors, violations of published standards, and other problems. The purpose of the review is to ensure that the output meets published standards and project requirements

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X12-An ANSI-accredited group that defines EDI standards for many American industries, including healthcare insurance. Most of the electronic transactions standards mandated or proposed under HIPAA are X12 standards.

X12 270-The X12 Health Care Eligibility and Benefit Inquiry transaction. The Eligibility and Benefit transactions are designed so that those who submit inquiries can: a) determine whether an information source, such as payer, employer, or HMO, has a particular subscriber or dependent on file; and b) view healthcare eligibility or benefit information about that subscriber and his or her dependents. The data available through these transaction sets is used to verify an individual's eligibility and benefits but cannot provide a history of benefit use. The information source may provide information about other organizations that may have third-party liability for coordination of benefits. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 271-The X12 Health Care Eligibility and Benefit Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 276-The X12 Health Care Claims Status Inquiry transaction - Claim Status Request/Claim Status Response. The 276 transaction set is used to request the current status of claims. The 277 transaction set can be used to: a) solicit response to a healthcare claim status request (276); b) provide notification about healthcare claim status, including front-end acknowledgments; or c) request additional information about a healthcare claim. The 276 is used only in conjunction with the 277 Health Care Claim Status Response. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 277-The X12 Health Care Claim Status Response transaction - Unsolicited Claim Status. A transaction set that can be used to transmit an unsolicited notification about a healthcare claim status. Version 4010 of this transaction has been included in the HIPAA mandates. This transaction is also expected to be part of the HIPAA claim attachments standard.

X12 278-The X12 Prior Authorization Review Request and Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 820-The X12 MCE Capitation Payment transaction - Premium Payment. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 834-The X12 Benefit Enrollment and Maintenance transaction -Enrollment/Maintenance. Used to transfer enrollment information from the sponsor (the party that ultimately pays for the coverage, benefit, or policy) to a payer - the party that pays claims or administers the insurance coverage, benefit, or product. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 835-The X12 Health Care Claim Payment and Remittance Advice transaction - Payment Advice. Contains information about the payee, payer, amount, and any identifying information of the payment. In addition, the 835 can authorize a payee to have a Depository Financial Institution take funds from the payer's account and transfer those funds to the payee's account. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 837-The X12 Health Care Claim or Encounter transaction - Dental/Professional/Institutional Claim. Intended to originate with the healthcare provider or the healthcare provider's designated agent. The 837 provides all necessary information to allow the destination payer to at least begin to adjudicate the claim. The 837 coordinates with a variety of other transactions, including the Claim Status (277), Remittance Advice (835), and Functional Acknowledgment (997). Version 4010 of this transaction has been included in the HIPAA mandates.

xover-cross over.

xref-cross-reference.

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yearly enrollment-Managed care re-enrollment opportunity that includes formal education on enrollment for all beneficiaries annually after the actual county conversion.

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ZIP Code-Formerly known as Zone or Postal Zone. A five-digit address extension signifying a postal delivery area in the United States. A four-digit addition has been added but is not required for postal delivery.

ZIP, ZIP file, ZIP format-An electronic file containing one or more compressed files with the extension .zip. A ZIP file requires extraction (decompression) of the files for them to be useable.

Wards of the court and foster children