Glossary of Terms
ATS -- Assistive Technology Supplier. Service providers who are involved with the sale, including determination of consumer needs and service of rehabilitation equipment, assistive technology and commercially available products and devices. Persons with an ATS credential have demonstrated a basic knowledge of rehabilitation equipment needs, including typical and atypical development, seating and positioning, augmentative/alternative communication, pathological conditions, ethical responsibilities and federal legislation.
CMS -- Centers for Medicare and Medicaid Services. The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Programs for which CMS is responsible include Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), HIPAA and CLIA. Formerly was HCFA. Centers for Medicare & Medicaid Services has historically maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.
Contract Provider -- Any hospital, physician, skilled nursing facility, extended care facility, individual, organization, or licensed agency that has a contractual arrangement with an insurer for the provision of services under an insurance contract.
Discharge Planning -- Required by Medicare and JCAHO for all hospital patients. A procedure where aftercare services are determined for after discharge from the inpatient facility.
DME -- Durable Medical Equipment. This is equipment which can: 1) withstand repeated use; 2) is primarily and customarily used to serve a medical purpose; 3) generally not useful to a person in the absence of an illness or injury; and 4) is appropriate for use in the home.
DMERC -- Durable Medical Equipment Regional Carrier. These carriers administer the processing of Medicare DME claims for specific regions - Region A, Region B, Region C, and Region D.
Fiscal Intermediary -- The agent (e.g., Blue Cross) that has contracted with providers of service to process claims for reimbursement under health care coverage. In addition to handling financial matters, it may perform other functions such as providing consultative services or serving as a center for communication with providers and making audits of providers' needs. This entity may also be referred to as TPA or third party administrator. A private organization, usually an insurance company, that serves as an agent for CMS which is part of HHS, that determines the amount of payment due to hospitals and other providers and paying them for the Medicare services they have provided. Intermediaries make initial coverage determinations and handle the early stages of beneficiary appeals.
HCP -- Health Care Provider. Providers of medical or health care, or researchers who provide health care are health care providers. Normally health care providers are clinics, hospitals, doctors, dentists, psychologists and similar professionals.
HCPCS -- HCFA Common Procedure Coding System. HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.
Home Health Care -- Full range of medical and other health related services such as physical therapy, nursing, counseling and social services that are delivered in the home of a patient, by a provider.
MCO -- Managed Care Organization. A health plan that seeks to manage care. Generally, this involves contracting with health care providers to deliver health care services on a capitated (per-member per-month) basis.
Part A Medicare -- Refers to the inpatient portion of benefits under the Medicare Program, covering beneficiaries for inpatient hospital, home health, hospice, and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and co-payments. Part A services are financed by the Medicare HI Trust Fund, which consists of Medicare tax payments. Part B, on the other hand, refers to outpatient coverage.
Part B Medicare -- Refers to the outpatient benefits of Medicare. Medicare Supplementary Medical Insurance (SMI) under Part B of Title XVII of the Social Security Act covers Medicare beneficiaries for physician services, medical supplies, and other outpatient treatment. Beneficiaries are responsible for monthly premiums, co-payments, deductibles, and balance billing. Part B services are financed by a combination of enrollee premiums and general tax revenues.
Payor (usually Third Party Payor) -- The public or private organization that is responsible for payment for health care expenses. Payors may be insurance companies or self-insured employers.
PAR -- Participating Supplier.
PMPM -- Per Member Per Month. Applies to a revenue or cost for each enrolled member each month. The number of units of something divided by member months. Often used to describe premiums or capitated payments to providers, but can also refer to the revenue or cost for each enrolled member each month. Many calculations, other than cost or premium, use PMPM as a descriptor.
Prior Authorization -- A formal process requiring a provider obtain approval to provide particular services or procedures before they are done. This is usually required for non-emergency services that are expensive or likely to be abused or overused. A managed care organization will identify those services and procedures that require prior authorization, without which the provider may not be compensated.
HIPAA – Health Insurance Portability and Accountability Act of 1996. A law mandating that anyone belonging to a group health insurance plan must be allowed to purchase health insurance within an interval of time beginning when the previous coverage is lost. The law protects employees (especially those with long term health conditions who may be reluctant to leave jobs because they are afraid pre-existing condition clauses will limit coverage of any such conditions under a new insurance plan) from losing health insurance due a change in employment status.
