Compliance Glossary of Terms
Collection of information from the medical record.
Payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Some inappropriate practices may initially be considerd abusive, but later involve fraud. See also "Fraud".
An evaluative process in which a healthcare organization undergoes an examination of it's policies, procedures, and performance by an external organization (accrediting body) to ensure that it is meeting predetermined criteria, usually involving both on and off-site surveys.
Term for legislation passed through Congress and signed by the President or passed over his veto. Also known as "Law" or "Statute".
The amount of money a provider of health services charges for a certain medical service or supply and is usually more than the insurance pays.
Process of determining whether a claim is paid.
Additional payment or correction of records on a previously processed claim.
Administrative Law Judge (ALJ)
Hears appeals of denied claims, as well as appeals from proposed OIG exclusions.
Advanced Beneficiary Notice (ABN)
Written notification given to a Medicare patient before a service is rendered, when the service may be denied or reduced because the service(s) may not be covered as medically reasonable and necessary according to the Medicare program. More information on Advanced Beneficiary Notice (ABN)...
Written document stating how a patient wants medical decisions to be made if they lose the ability to make decisions for themselves. May include a Living Will and a Durable Power of Attorney for health care. More information on Advanced Directive...
OIG issued opinion to an individual or entity regarding the legality of specific activities and transactions under the Anti-Kickback Statute. More information on Advisory Opinion...
Alternate Level of Care (ALC (or) ALOC)
Patients who no longer need hospital or skilled nursing facility care. More information on Alternate Level of Care (ALC (or) ALOC)...
American Academy of Nurse Practitioners (AANP)
Advocate group for nurse practitioner issues. More information on American Academy of Nurse Practitioners (AANP)...
American Academy of Physician Assistants
National professional society for Physician Assistants. More information on American Academy of Physician Assistants...
American Association of Colleges of Nursing (AACN)
Advances higher education in nursing. More information on American Association of Colleges of Nursing (AACN)...
American Association of Medical Colleges (AAMC)
Non-profit group of medical schools, teaching hospitals and academic societies. More information on American Association of Medical Colleges (AAMC)...
American Association of Professional Coders (AAPC)
Provides education and professional training for medical coders. More information on American Association of Professional Coders (AAPC)...
American Association of Retired Persons (AARP)
Non-profit, nonpartisan organization helping people over age 50 improve their quality of life. More information on American Association of Retired Persons (AARP)...
American Bar Association (ABA)
Professional association providing law school accreditation, continuing legal education, law information and initiatives to improve the legal profession. More information on American Bar Association (ABA)...
American College of Emergency Physicians (ACEP)
Promotes the interests of emergency department physicians and patients. More information on American College of Emergency Physicians (ACEP)...
American College of Healthcare Executives (ACHE)
International professional society that advances healthcare management excellence through education and research. More information on American College of Healthcare Executives (ACHE)...
Americans with Disabilities Act of 1990 (ADA)
Law that prohibits discrimination and ensures equal opportunities for persons with disabilties in employment, State and local government services, public accomodations, commercial facilities, transportation and telephone relay services. More information on Americans with Disabilities Act of 1990 (ADA)...
American Health Information Management Association (AHIMA)
Provides medical record professionals with educational resources and programs. More information on American Health Information Management Association (AHIMA)...
American Health Lawyers Association (AHLA)
Addresses legal issues in the healthcare field. More information on American Health Lawyers Association (AHLA)...
American Health Quality Association (AHQA)
Represents Quality Improvement organizations and professionals working to improve healthcare quality. More information on American Health Quality Association (AHQA)...
American Hospital Association (AHA)
National organization representing hospitals, healthcare networks, patients and communities. More information on American Hospital Association (AHA)...
American Medical Association (AMA)
Professional organization that promotes the art and science of medicine and the betterment of public health. More information on American Medical Association (AMA)...
Ambulatory Payment Classification (APC)
Result of the Balanced Budget Act. Outpatient prospective payment system that transfers financial risk from Medicare to the provider of outpatient services. APC's group similar clinical services together for reimbursement purposes. More information on Ambulatory Payment Classification (APC)...
Professional services by a hospital or other inpatient health program that may include x-ray, drug, laboratory or other services.
Anti-Kickback Statute (AKS)
Statute under the Social Security Act that prohibits the offer, payment, solicitation or receipt of any form of remuneration for services rendered. More information on Anti-Kickback Statute (AKS)...
Related to price information, referrals, amd discriminatory pricing. More information on Anti-Trust...
Licensed physician who would normally be expected to certify and recertify the medical necessity for the number of services rendered and/or who has primary responsibility for the patient's medical care and treatment.
Attorney General (NYS) (AG)
Chief Legal Officer for New York State whose office serves as the guardian of legal rights of the citizens and organizations of New York Stae and New Yorks national rsources. More information on Attorney General (NYS) (AG)...
Average Wholesale Price (AWP)
Generally accepted standard of measurement for calculating the cost of particular drugs which wholesalers sell to physicians, pharmacies and other customers.
Difference between billed amount and amount approved by insurer.
Balanced Budget Act (1997) (BBA)
Balanced Budget Act of 1997-- Law that changes sections of the Social Security Act, including several anti-fraud and abuse provisions and improvements to protect the Medicare programs integrity. More information on Balanced Budget Act (1997) (BBA)...
Person eligible to receive Medicare or Medicaid payment and/or services.
Gift to beneficiary to influence them to receive care by a specific provider. More information on Beneficiary Inducement ...
A certificate of ownership of a specified portion of a debt due by the federal government to holders, bearing a fixed rate of interest.
An insurance company that contracts with CMS and has determined reasonable charges, accuracy, and coverage for Medicare Part B services and processes Part B claims and payments.
A process used by a doctor, nurse, or other health professional to manage your health care. Case managers make sure patients receive needed services and track use of facilities and resources.
Distribution of patients into categories reflecting differences in the severity of illness or resource consumption.
Case Mix Index (CMI)
The average DRG relative weight for all Medicare admissions.
Centers for Disease Control (CDC)
Component of the DHHS to assist in the prevention of disease. More information on Centers for Disease Control (CDC)...
Centers for Medicare & Medicaid Services (CMS)
Federal agency, part of DHHS that administers and oversees the Medicare program and a portion of the state Medicaid program. Responsibilities include managing contractor claims payment, fiscal audit and/or overpayment prevention and recovery and developing and monitoring payment safeguards necessary to detect and respond to payment errors or abusive patterns of service delivery. More information on Centers for Medicare & Medicaid Services (CMS)...
Certified Home Health Agency (CHHA)
Provider of intermittent healthcare and support services to individuals requiring intermediate levels of care. More information on Certified Home Health Agency (CHHA)...
Charge Description Master (Chargemaster) (CDM)
Comprehensive listing of items that could be billed to a patient, payer or hralthcare provider.
Civil Monetary Penalty (CMP)
Regulations which apply to any claim for services that was not provided as claimed or that was knowingly submitted as false and which provides guidelines for levying fines for such offenses. More information on Civil Monetary Penalty (CMP)...
Civilian Health & Medical Programs of the Uniformed Services (TRICARE) (CHAMPUS)
Federally funded health program proooviding benficaries with medical care supplemntal to that available inmilitary facilities. Now called TRICARE. More information on Civilian Health & Medical Programs of the Uniformed Services (TRICARE) (CHAMPUS)...
Civilian Health & Medical Programs of the Veteran's Affairs (CHAMPVA)
Healthcare coverage for military families not eligible under CHAMPS/TRICARE. More information on Civilian Health & Medical Programs of the Veteran's Affairs (CHAMPVA)...
Child Health Insurance Program (CHIP)
Health insurance program providing coverage for uninsured children. More information on Child Health Insurance Program (CHIP)...
Request for payment of benefits or services rendered by a provider or received by an insured individual.
Clinical Laboratory Improvement Act (CLIA)
Clinical Laboratory Improvement Act of 1965 (Amended in 1988)-- Legislation that set quality and performance standards for all laboratory testing. CLIA standards are national and are not Medicare exclusive. CLIA applies to all providers rendering clinical laboratory and certain other diagnostic services, whether or not claims are filed to Medicare. More information on Clinical Laboratory Improvement Act (CLIA)...
Code of Federal Regulations (CFR)
Official compilation of federal rules and regulations. More information on Code of Federal Regulations (CFR)...
Amount that insurance will not pay. The patient or the patient's secondary insurance company is responsible for this amount.
Adherence to the requirements of applicable laws and regulations.
Complication or Co-Morbidity (CC)
Significant acute disease, significant acute manifestation of a chronic disease, an advanced or end stage chronic disease or a chronic disease associated with systemic physiological decompensation and debility that have consistently greater impact on hospital resources.
Comprehensive Error Rate Testing (CERT)
Program to calculate national paid claims error rate for all Medicare Fee-for-Service programs. More information on Comprehensive Error Rate Testing (CERT)...
Conditions of Participation (COP)
Minimum health and safety standards that must be met in order to participate in the Medicare and medicaid programs. More information on Conditions of Participation (COP)...
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
Gives workers and their families who lose healthcare benefits the right to choose to continue their group health benefits for limited periods under certain circumstances. More information on Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)...
Continuous Quality Improvement (CQI)
A process which continually monitors program performance. When a quality problem is identified, CQI develops a revised approach to the problem and monitors implementation and success of the revised approach. The process includes involvement at all stages by all organizations which are affected by the problem and/or involved in implementing the revised approach.
Coordination of Benefits (COB)
Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim.
Corporate Integrity Agreement (CIA)
A negotiated settlement between a health care provider and the government in which the provider accepts no liability but must agree to implement a strict plan of government-supervised corrective action. More information on Corporate Integrity Agreement (CIA)...
Correct Coding Initiative (CCI)
CMS program to provide national correct coding methodologies and to control improper coding which leads to improper payments. More information on Correct Coding Initiative (CCI)...
Corrective Action Plan (CAP)
Plan implemented to remedy identified non-compliant situations. More information on Corrective Action Plan (CAP)...
A report required from providers annually to make a proper determination of amounts payable under the Medicare program. More information on Cost Report...
Reasonable and medically necessary services rendered to patients and reimbursable to the provider.
Current Procedural Terminology (CPT)
System of uniform medical procedure codes to identify specific healthcare services performed. Developed by the AMA and used by most insurers and providers for billing purposes.
Custodial Level of Care (CLOC)
Non-skilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in/out of bed/chair, moving around, or using the bathroom.
Date of Service (DOS)
Days that a patient receives specific services that are billed for.
Amount a patient must pay before insurance begins to pay for covered services and supplies.
Deficit Reduction Act (DRA)
Federal Law effective 1/1/07 affecting entitlement programs (i.e. Medicare). Medicaid and Social Security requiring mandatory compliance program components for entities receiving more than $5 million per year from Medicaid. More information on Deficit Reduction Act (DRA)...
Department of Defense (DOD)
United States Department of Defense More information on Department of Defense (DOD)...
Department of Health and Human Services (DHHS/HHS)
United States Department of Health and Human Services-- Administers many of the federal "social" programs dealing with the health and welfare of the citizens of the USA. Parent of the Centers for Medicare and Medicaid Services (CMS). More information on Department of Health and Human Services (DHHS/HHS)...
Department of Housing & Urban Development (HUD)
Creates strong, sustainable, quality and affordable housing for all. More information on Department of Housing & Urban Development (HUD)...
Department of Justice (DOJ)
Enforces the law and defends the interests of the U.S. More information on Department of Justice (DOJ)...
Department of Labor (DOL)
Seeks to improve working conditions, benefits and rights of wage earners, job seekers and retirees. More information on Department of Labor (DOL)...
Department of Social Services (Onondaga County) (DSS)
Provides public benefit and casework programs. More information on Department of Social Services (Onondaga County) (DSS)...
Det Norske Veritas Healthcare (DNV)
Healthcare accreditation organization. More information on Det Norske Veritas Healthcare (DNV)...
Diagnosis Related Group (DRG)
System that groups patients according to principal diagnosis, presence of a surgical procedure, age, presence or absence of significant complications, etc. More information on Diagnosis Related Group (DRG)...
Diagnostic & Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)
Manual published by the American Psychiatric Association covering all mental health disorders, causes and prognosis.
Disproportionate Share Hospital (DSH)
A hospital with a disproportionately large share of low-income patients. Under Medicaid, New York State augments payments to the hospital and Medicare inpatient hospital payments are also adjusted to help reimburse costs. More information on Disproportionate Share Hospital (DSH)...
Illegal practice of intentionally billing using a DRG which provides a higher payment rate than the DRG that accurately reflects the diagnosis and treatment actually provided.
Drug Enforcement Agency or Administration (DEA)
Federal organization enforcing controlled substance laws/regs. More information on Drug Enforcement Agency or Administration (DEA)...
Durable Medical Equipment (DME)
Purchased or rented items such as hospital beds, oxygen equipment, wheelchairs and other reusable medical equipment to be used in a patient's home. More information on Durable Medical Equipment (DME)...
Durable Medical Equipment Prosthetic, Orthotics & Supplies (DMEPOS)
N/A More information on Durable Medical Equipment Prosthetic, Orthotics & Supplies (DMEPOS)...
Durable Medical Equipment Regional Carrier (DMERC)
A private company that contracts with an insurance company to pay bills for durable medical equipment.
Durable Power of Attorney (POA)
A legal document that enables you to designate another person, called the attorney in-fact, to act on your behalf, in the event you become disabled or incapacitated.
Electronic Data Interchange (EDI)
Exchange of routine business transactions from one computer to another in a standard format using standard communication protocols.
Electronic Medicaid Elegibility Verification System (EMEVS)
System allowing electronic verification of Medicaid benfits.
Emergency Medical Treatment and Active Labor Act (EMTALA)
Law requiring hospitals to provide an examination and stabilization without consideration of insurance coverage or ability to pay when a patient presents to the Emergency Department for treatment. More information on Emergency Medical Treatment and Active Labor Act (EMTALA)...
Employee Retirement Income Security Act (ERISA)
A 1974 Federal act that exempts self-insured health plans from state laws governing health insurances and requires health plans to provide certain information to enrollees. More information on Employee Retirement Income Security Act (ERISA)...
Employer Identification Number (EIN)
Also known as a federal tax identification number and is used to odentify business entities. More information on Employer Identification Number (EIN)...
End Stage Renal Disease (ESRD)
Permanent kidney failure requiring dialysis or kidney transplant. More information on End Stage Renal Disease (ESRD)...
Environmental Protection Agency (EPA)
Mission is to protect human health and environment. More information on Environmental Protection Agency (EPA)...
Equal Employment Opportunity Commission (EEOC)
U.S. Agency created in 1964 to end discrimination based on race, religion, sex or national origin in employment. The commission reviews and investigates charges of discrimination and, if found to be true, attempts to remedy through concilation or legal means. More information on Equal Employment Opportunity Commission (EEOC)...
Evaluation and Management Services (E/M)
Refers to visits and consultations furnished by physicians, who then utilize a common set of codes for billing purposes to describe services provided.
Situtation or condition where coverage is disallowed by a subscriber's contract. DHHS/OIG penalty imposed on a provider prohibiting the provider from billing Medicare or other government programs.
OIG list of providers, individuals, and entitites that are excluded from Medicare reimbursement. Includes identifying information about the sanctioned party, specialty, notice date, sanction period and sections of the Social Security Act used in arriving at the determination to impose a sanction. The OIG sanctioned provider list is available online at http://exclusions.oig.hhs.gov/cgi-bin_counter.pl and click "search". Debarment, exclusion and suspension lists for all federal agencies are available online at http://epls.arnet.gov under "EPLS Reports Menu". More information on Exclusion List...
Executive Order 127 (New York State)
Mandates mandatory disclosure of anyone attempting to influence SUNY persons in bid proposals by prospective contractors. More information on Executive Order 127 (New York State)...
Any treatment, procedure, equipment, drug, drug usage, device, or supply not generally recognized as accepted medical practice. Includes services or supplies requiring federal or other government approval not granted at the time services were rendered.
Explanation of Benefits (EOB)
Statement sent by a health insurance company to covered individuals explaining what medical treatment and/or services were paid or not paid on their behalf.
False Claims Act (Federal) (FCA)
Federal legislation that prohibits knowingly filing a false or fraudulent claim to the government for payment, knowingly using a false record or statement to obtain payment on a false or fraudulent claim paid by the government and conspiring to defraud the government by getting a false or fraudulent claim allowed or paid. More information on False Claims Act (Federal) (FCA)...
False Claims Act for New York State (FCA (NYS))
Effective in 2007. Follows most of the same prohibitions as the Federal FCA.
Federal Aviation Administration (FAA)
Mission is to provide safe and efficient aerospace. More information on Federal Aviation Administration (FAA)...
Federal Bureau of Investigation (FBI)
Protects, defends and enforces U.S. law against: Terrorism, Counterintelligence, Cyber Crime, Public Corruption, Civil Rights Violations, Organizaed Crime, White Collar Crime, Violent Crime And Major Thefts. More information on Federal Bureau of Investigation (FBI)...
Federal Communications Commission (FCC)
Regulates interstate and international communications via radio, TV, wire, satellite and cable. More information on Federal Communications Commission (FCC)...
Federal Emergency Management Agency (FEMA)
Prepares for, protects and responds to all hazards. More information on Federal Emergency Management Agency (FEMA)...
Federal Insurance Contributions Act (FICA)
Law requiring part of worker's pay to be withheld for Social Security.
Federal Register (FR)
The official daily publication for rules, proposed rules and notices of federal agencies and organizations, as well as excecutive orders and other presidential documents. More information on Federal Register (FR)...
Federal Sentencing Commission (USSC)
Federal organization that establishes sentencing guidelines for federal courts, including the form and severity of punishment for offenders convicted of a federal crime. More information on Federal Sentencing Commission (USSC)...
A complete listing of fees used by health plans to pay doctors or other providers.
Fiscal Intermediary (FI)
CMS contractor that determines reasonable charges, accuracy and coverage for Medicare Part A services and processes Part A claims and payments.
Food & Drug Administration (FDA)
Federal agency responsible for protecting public health by assuring the safety, efficacy and security of human and veterinary drugs, biologicals, medical devices, national food supply, cosmetics and products emitting radiation. More information on Food & Drug Administration (FDA)...
Knowing and willfull execution, or attempt at execution, of a scheme or artifice to defraud any healthcare benefit program, or to obtain, by means of false or fraudulent pretenses, representations, or promises, any money or property owned by, or under the custody or control of any healthcare benefit program. See also abuse.
OIG issuances regarding practices that the OIG considers suspect or of particular concern.
Fraud and Abuse (F & A)
See "Fraud". See "Abuse".
Fraud Enforcement and Recovery Act (FERA)
Act established to improve enforcement of mortgage fraud, securities fraud, financial institution fraud, and other frauds related to federal assistance and relief programs, for the recovery of funds lost to these frauds, and for other purposes. More information on Fraud Enforcement and Recovery Act (FERA)...
Freedom of Information Act (or Law) of 1966 (FOIA (or FOIL)
A provision that any person has a right, enforceable in court, or access to any federal agency records, except to the extent that such records or portions thereof, are protected from disclosure by one of the nine exemptions or by one of three special law enforcement record exclusions. More information on Freedom of Information Act (or Law) of 1966 (FOIA (or FOIL)...
General Services Administration (GSA)
Federal agency that manages the federal government's property and records, including the construction and operation of buildings and procurement and distribution of supplies, among other functions. More information on General Services Administration (GSA)...
Combined technical (equipment) and professional (physician) charges or payment.
Government Accounting Office (GAO)
Investigative arm of Congress charged with examining matters related to receipt of public funds. More information on Government Accounting Office (GAO)...
Government Printing Office (GPO)
Provides publishing and dissemination of government publications. More information on Government Printing Office (GPO)...
Gross Domestic Product (GDP)
The amount of (market value) goods and services produced in a year in a country and usually correlates to the standard of living.
Hospital uniform billing claim or UB-92.
Professional uniform billing form or UCF-1500
Healthcare Association of New York State (HANYS)
N/A More information on Healthcare Association of New York State (HANYS)...
Health Care Financing Administration (HCFA)
Former name of Centers for Medicare & Medicaid Services. See CMS. A component of the U.S. Department of Health and Human Services that administers the Medicare program and some aspects of state Medicaid programs.
Healthcare Common Procedure Coding System (HCPCS)
Uniform method for providers and suppliers to report professional services, procedures and supplies. HCPCS includes CPT codes (Level I), national alphanumeric codes (Level II) and local codes (Level III) assigned and maintained by local Medicare contractors.
Healthcare Financial Management Association (HFMA)
An organization promoting involvement of the financial management of healthcare related organizations. More information on Healthcare Financial Management Association (HFMA)...
Health Care Quality Improvement Program (HCQIP)
Promotes the quality, effectiveness and efficiency of services to Medicare beneficiaries by monitoring and improving quality of care, improving ion between beneficiaries and providers, promoting informed health choices and protecting beneficiaries from poor care.
Health Insurance Portability and Accountability Act (HIPAA)
Health Insurance Portability and Accountability Act of 1996-- One provision imposes significant changes to fraud and abuse controls. Another provision protects health insurance coverage for workers and their families when they change or lose their jobs, including those with pre-existing conditions. More information on Health Insurance Portability and Accountability Act (HIPAA)...
An entity that assumes the risk of paying for medical treatments.
Healthplan Employer Data Information Set (HEDIS)
A set of standard performance measures providing information about the quality of a health plan. Measures include quality of care, access, cost, etc that compare one plan to another. More information on Healthplan Employer Data Information Set (HEDIS)...
Health Maintenance Organization (HMO)
Organizations that combine the functions of insurers and providers of care, giving most necessary medical care for a prepaid fee and placing emphasis on prevention and careful assessment of medical necessity.
A person trained or licensed to give healthcare or a place licensed to give healthcare.
Home Health Agency (HHA)
An organization that gives home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy and personal care by home health aides.
Home Health Care (HHC)
Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech therapy, medical social services, durable medical equipment, medical supplies and other services.
Special way of caring for people who are termically ill, including physical care and counseling.
A doctor who primarily takes care of patients when they are in the hospital. This doctor will take over care from the primary physician while the patient is hospitalized, keeps the primary physician informed regarding progress and returns patient to care of primary physician upon discharge from the hospital.
Hospital Acquired Condition (HAC)
Conditions that are high cost and/or volume resulting in the assignement to a DRG that has a higher payment when present as a secondary diagnosis and could reasonably have been prevented theough the application of evidence-based practice guidelines. More information on Hospital Acquired Condition (HAC)...
Resource locater provided by CMS. More information on Hospital Compare...
Hospital Issued Notice of Non-Coverage (HINN)
A notice issued ot Medicare beneficiaries by a hospital when the hospital believes the care the beneficiary is receving, or about to receive, would not be covered by Medicare because it is not medically necessary, is not being delivered in the most appropriate setting or would be custodial in nature. More information on Hospital Issued Notice of Non-Coverage (HINN)...
A common reporting system giving anonymous telephone access to employees seeking to report possible instances of wrong-doing.
Services rendered by employees of physicians or physician-directed clinics, when the services provided are integral, though incidental, to the physician's professional service. More information on Incident To...
Inspector General (IG)
Investigative official in a civil or military organization.
Intermediate Care Facility (ICF)
A healthcare facility for individuals who are disabled, elderly or mentally ill, usually providing less intensive care than that offerred at a hospital or SNF.
Management systems and policies that reasonably document, monitor and correct operational processes to prevent and detect waste and to ensure proper payments.
International Classification of Diseases, 9th Rivision, Clinical Modification (ICD-9-CM)
A national coding method to enable providers to effectively document the medical condition, symptom or complaint that is the basis for rendering a specific service. The coding system consists of 3-5 character numeric or alphanumeric codes for reporting purposes. More information on International Classification of Diseases, 9th Rivision, Clinical Modification (ICD-9-CM)...
International Classification of Diseases, 10th Revision (ICD-10)
Coding methodology for medical diagnosis and inpatient procedures effective 10/1/13. Replaces ICD-9-CM. More information on International Classification of Diseases, 10th Revision (ICD-10)...
Internal Revenue Service (IRS)
United States tax collection agency. More information on Internal Revenue Service (IRS)...
Island Peer Review Organization (IPRO)
Contracts with federal government to provide healthcare reviews related to quality and billing. More information on Island Peer Review Organization (IPRO)...
A subset of HCPCS used to identify certain drugs and other items.
Joint Commission for Accreditation of Health Organizations (JCAHO)
An organization that accredits healthcare organizations. More information on Joint Commission for Accreditation of Health Organizations (JCAHO)...
Joint Commission on Public Ethics (NYS) (JCOPE)
New York State agency. More information on Joint Commission on Public Ethics (NYS) (JCOPE)...
Situation in which a business agrees to pay a physician for every patient referred for a specific study or other service. This is prohibited by federal law. See Anti-Kickback Statute.
Length of Stay (LOS)
Term commonly used to measure the duration of a single episode of hospitalization.
Level of Care (LOC)
Intensity of medical care being provided by the physician or health care facility.
Lifetime Reserve Days
A period of 60 days that Medicare will pay for when a patient is hospitalized more than 90 days during a benefit period. Reserve days can only be used once during the patient's lifetime. More information on Lifetime Reserve Days...
List of Excluded Individuals & Entitities (LEIE)
Database providing info to healthcare industry,patients and public regarding individuals and entities that are currently excluded from participation in Medicare, Medicaid and other federal health care programs. More information on List of Excluded Individuals & Entitities (LEIE)...
A legal document also known as a medical directive or advanced directive. It states patient's wishes regarding life-support or other medical treatment in certain circumstances, usually when death is imminent. More information on Living Will...
Local Coverage Determination (LCD)
Formal document developed through a specifically defined process that provides criteria for claim and review of payment decisions to ensure that suitability of the carrier's medical policies, medical care and review guidelines are consistent with standards of medical practice. Formerly known as LMRP. More information on Local Coverage Determination (LCD)...
Local Medical Review Policy (LMRP)
Long Term Care Facility (LTCF)
Facility offerring skilled extended care of a patients physical and emotional needs.
Major Complication or Comorbidity (MCC)
Major Diagnosis Category (MDC)
Diagnosis grouped into single organ systems associated with particular medical specialties used primarily as a billing element for healthcare reimbursement as part of the DRG system.
Managed Care Operation (MCO)
An insurance plan that only allows you to see certain doctors, specialists or hospitals on the plan's list, unless you want to pay extra to go out of network.
Joint federal and state program established by Title XIX of the Social Security Act which helps with medical costs for some people of all ages who have low incomes and limited resources. The program varies from state to state.
Medicaid Fraud Control Unit (MFCU)
Investigates and prosecutes Medicaid fraud and patient abuse/neglect in healthcare facilities. More information on Medicaid Fraud Control Unit (MFCU)...
Medicaid Integrity Contractor (MIC)
Hired by CMS to review Medicaid provider contracts, audit claims, identify overpayments and educate providers. More information on Medicaid Integrity Contractor (MIC)...
Medicaid Integrity Program (MIP)
CMS program to combat Medicaid provider fraud, waste and abuse. More information on Medicaid Integrity Program (MIP)...
Services or supplies that are proper and needed for the diagnosis or treatment of a medical condition, provide for the diagnosis, direct care and treatment of a medical condition, meet the standards of good medical practice in the area and are not done mainly for the convenience of the physician.
Medicare Administrative Contractor (MAC)
Hired by CMS to administer the Medicare program and insure quality healthcare for Medicare benficiaries. More information on Medicare Administrative Contractor (MAC)...
Medicare Integrity Program
Created by Congress as part of the HIPAA Act of 1996 to provide a stable source of funding for program integrity efforts to support the Medicare program via cost report audits, medical review, anti-fraud activities and Medical Secondary Payer review. More information on Medicare Integrity Program...
Provider group that aggressively seeks out Medicare patients.
Medicare Modernization Act (MMA)
Medicare Part A
Title XVIII of the Social Security Act which provides insurance for hospital, skilled nursing facility, home healthcare and hospice costs to workers and beneficiaries insured under Social Security, certain dependants and certain disabled Social Security beneficiaries. More information on Medicare Part A...
Medicare Part B
Titles XVIII of Social Security Act which provides insurance for physician services, outpatient hospital care and various other services such as ambulance and laboratory services. DME and PT/OT to workers and beneficiaries insured under Social Security, certain dependants and cetain disabled Social Security beneficiaries. More information on Medicare Part B...
Medicare Part C
Medicare Advantage: Health Maintenance Organization that provides healthcare services to Medicare beneficiaries (except ESRD) who are entitled to part A and enrolled in Part B and who want to enroll in a Medicare Advantage plan and who live in a particular service area. More information on Medicare Part C...
Medicare Part D
Prescription drug coverage provided to all Medicare beneficiaries who elect to enroll in a Prescription Drug Plan. More information on Medicare Part D...
Medicare Secondary Payer (Questionnaire) (MSP (or) MSPQ)
Statutory requirement that under certain circumstances private or other government insurance programs available to beneficiaries be exhausted before Medicare must pay. More information on Medicare Secondary Payer (Questionnaire) (MSP (or) MSPQ)...
Medicare Severity Diagnosis Related Groups (MS-DRG)
A Medicare supplemental insurance policy sold by private insurance companies to fill the "gaps" in the original Medicare coverage plan.
Memorandum of Understanding (MOU)
A document providing a general description of the responsibilities that are to be assumed by two or more parties in their pursuit of some goal(s).
National Correct Coding Initiative (NCCI)
See "CCI" Correct Coding Initiatives
National Coverage Determination (NCD)
Sets for the extent to which Medicare will cover specific services, procedures or technologies on a national basis. If an NCD does not specifically exclude/limit a circumstance or if the item is not mentioned at all in the NCD or in a Medicare manual, it is up to the local Medicare contractor to make a local coverage determination. See LCD. More information on National Coverage Determination (NCD)...
National Government Services (NGS)
Medicare contractor that acts as the Fiscal Intermediary for CMS in the New York State region. More information on National Government Services (NGS)...
National Institutes of Health (NIH)
Federal agency that provides leadership and direction to programs designed to improve the health of the U.S. by conducting and supporting research. More information on National Institutes of Health (NIH)...
National Library of Medicine
N/A More information on National Library of Medicine ...
National Practitioner Data Bank (NPDB)
A federal repository established pursuant to the Health Care Quality Improvement Act of 1986 that contains information regarding physicians and other health care providers relating to professional competence malpractice claim settlements or judgements. More information on National Practitioner Data Bank (NPDB)...
National Provider Identifier (NPI)
A system for uniquely identifying all providers of health care services, supplies and equipment. More information on National Provider Identifier (NPI)...
Medical errors that should "never" occur. More information on Never Event...
New York Code of Rules & Regulations (NYCRR)
Includes Title 10 More information on New York Code of Rules & Regulations (NYCRR)...
New York State Department of Health (NYSDOH)
N/A More information on New York State Department of Health (NYSDOH)...
New York State Finance Law
N/A More information on New York State Finance Law...
Insurance that pays for health care services resulting from injury to you or damage to your property regardless of who is at fault for causing the accident.
Drugs not on an approved list.
Occupational Safety and Health Administration (OSHA)
A component of the Department of Labor that develops and adminsters standards relating to the well-being of workers at the job-site, develops and issues regulations in this area, conducts investigations and inspections to determine status of compliance with safety and health standards and regulations and issues citations and proposes penalties for non-compliance. More information on Occupational Safety and Health Administration (OSHA)...
Office of Civil Rights (OCR)
Federal agency promoting the enforcement of civil rights.
Office of Inspector General (OIG)
An organizational component of the Office of the Secretary, DHHS. Responsible for conducting and supervising audits, investigations and inspections relating to the programs and operations of DHHS, including Medicare and Medicaid. OIG provides leadership and coordination, recommends policies and corrective actions, prevents and detects fraud and abuse in DHHS programs and operations and is responsible for all DHHS criminal investigations including Medicare fraud whether committed by contractors, grantees, beneficiaries or providers of service. More information on Office of Inspector General (OIG)...
Office of Medicaid Inspector General (OMIG)
NYS agency that attempts to prevent and detect fraud, waste and abuse within the NYS Medicaid program. More information on Office of Medicaid Inspector General (OMIG)...
Office of Professional Medical Conduct (OPMC)
Investigates complaints related to physicians, specialized assistants and physician assistants. More information on Office of Professional Medical Conduct (OPMC)...
Office of the Professional Discipline (OPD)
NYS Department of Education division which investigates misconduct by professional licensees other than MD, PA and specialist assistants. More information on Office of the Professional Discipline (OPD)...
Omnibus Budget Reconciliation Act (OBRA)
Omnibus Budget Reconciliation Act of 1995-- Extension of Stark law regarding self-referrals.
www.health.state.ny.us/nysdoh/hospital More information on Operating Certificate...
Operation Restore Trust (ORT)
Federal program that investigates, identifies and reduces/eliminates health care fraud. Focused on fraud/abuse in Medicare billing practices, physician/hospital relationships to labs and other providers.
Organ Procurement Organization (OPO)
An organization that performs or coordinates the retrieval, preservation and transportation of organs and maintains a system of locating prospective recipients for available organs.
Anything that falls outside a considered norm.
Outpatient Prospective Payment System (OPPS)
The way that Medicare pays for most outpatient services at hospitals under Medicare Part B.
Patient Protection & Affordable Care Act (PPACA)
Health care reform act signed into law on 3/23/10 by President Obama. More information on Patient Protection & Affordable Care Act (PPACA)...
Payment Error Rate Measurement (PERM)
PERM program measures improper payments in Medicaid and CHIP and produces error rates for each program More information on Payment Error Rate Measurement (PERM)...
Peer Review Organization (PRO)
Organization contracting with CMS to review medical necessity and quality of care provided to Medicare beneficiaries.
A gauge used to assess the performance of a process or function of any organization.
Pharmaceutical Manufacturers and Researchers of America (PHRMA)
Organization that represents he interests of research-based pharmaceutical and biotechnology companies within the U.S. More information on Pharmaceutical Manufacturers and Researchers of America (PHRMA)...
Point of Service (POS)
Place of Service that a patient receives care.
Power of Attorney (POA)
A document that lets you appoint someone you trust to make decisions about your medical care. See Durable Power of Attorney.
Present on Admission (POA)
Diagnosis present at time of inpatient admission. Whether a diagnosis occurs prior to or after admission impacts reimbursment. More information on Present on Admission (POA)...
Primary Care Physician (PCP)
Doctos who provide a basic level of care, usually general and family medicine, internists, obstetricians and pediatricians.
Program for Evaluating Payment Patterns Electronic Report (PEPPER)
An electronic data report containing hospital-specific data for 13 target areas â€” specific Diagnosis Related Groups (DRGs) and discharges that have been identified as at high risk for payment errors. More information on Program for Evaluating Payment Patterns Electronic Report (PEPPER)...
Progressive Corrective Action (PCA)
Used by CMS to identify and target problem providers based on data. Emphasis is on education. Formerly known as focused medical review.
Prospective Payment System (PPS)
The system for paying services for Medicare patients (see DRG) whereby patients are classified into categories for which prices are negotiated or determined in advance. More information on Prospective Payment System (PPS)...
Protected Health Information (PHI)
Health information transmitted and maintained in any form which is held by a covered entity or its business associate that identified individuals or offers a reasonable basis for identification, is created or received by a covered entity or an employer, related to past, present or future physical or mental conditions, provision of health care or payment for health care. More information on Protected Health Information (PHI)...
Generic term for any person, i.e. physician, entity, home health agency, skilled nursing facility, hospital, etc approved to provide care to Medicare beneficiaries and to receive payment from Medicare.
Provider Identification Number (PIN)
Unique individual provider number issued to a provider by the local Medicare contractor allowing the physician or patient to receive reimbursement for claims filed to the contractor.
Public Employees Ethics Reform Act (PEERA)
New York State Law effective 4/25/07 which had significant changes on the NYS Public Officers Law regarding gift acceptance, nepotism, contracting decisions and political donations. More information on Public Employees Ethics Reform Act (PEERA)...
Public Officers Law (NYS) (POL)
Section 73 & 74 provides standards of conduct for New York employees restricting certain business and professional activities while in state service and after leaving state service. More information on Public Officers Law (NYS) (POL)...
Quality Improvement Organization (QIO)
A group of health care experts paid by the federal government to check and improve care given to Medicare patients who review complaints about quality of care.
Quality Improvement Process (QIP)
The "Whistle Blower" provision that allows any person having knowledge of a false claim against the government to bring action against the suspected wrongdoer on behalf of the United States Government. More information on Qui Tam...
Racketeer Influenced and Corrupt Organization Act (RICO)
Federal law providing extended criminal penalties for acts performed as part of an on-going criminal organization. (i.e. organized crime ring) More information on Racketeer Influenced and Corrupt Organization Act (RICO)...
Recovery Audit Contractor (RAC)
Program designed to detect and correct improper payments in the Medicare FFS program. More information on Recovery Audit Contractor (RAC)...
Relative Value List (RVL)
Physician Fee Schedule More information on Relative Value List (RVL)...
Resource Based Relative Value Use (RBRVU)
Medicare fee schedule for physician services that set a uniform payment in each geographic area for most medical procedures. More information on Resource Based Relative Value Use (RBRVU)...
Resource Utilization Group (RUG)
Patient classification system for nursing home patients used by the federal government to determine reimbursement levels for nursing home care. More information on Resource Utilization Group (RUG)...
Return on Investment (ROI)
Ratio of money gauned or lost on an investment relative to the amount of money invested (profit/loss)
Provisions that protect certain individuals, providers or entities from criminal prosecution and/or civil sanctions when certain requirements are met for actions which may appear as unlawful or inappropriate according to Medicare law. More information on Safe Harbor...
Sarbanes-Oxley Act (SOX)
Act to prevent, detect, and address misconduct within an organization with emphasis on auditing, accounting and financials. More information on Sarbanes-Oxley Act (SOX)...
An insurance policy, plan or program that pays second in a claim for medical care.
An unexpected occurrence involving death or serious physical or psychological injury or risk thereof. More information on Sentinel Event...
Skilled Nursing Facility (SNF)
Establishment that houses chronically ill, usually elderly, patients and provides long-term nursing care, rehabilitation or other services.
Social Security Act (SSA)
Public Law 74-271 enacted in 1935 consisting of 20 titles. More information on Social Security Act (SSA)...
Social Security Administration (SSA)
Federal agency that adminsters various programs funded under the Social Security Act and determines eligibility for Medicare benefits. More information on Social Security Administration (SSA)...
Law implemented in 1995 that prohibits a physician or his immediate family from having a financial relationship with an entity to which Medicare patients are referred to receive a designated health service. More information on Stark...
State Child Health Insurance Program (SCHIP)
Free or low cost health insurance available for children under the age of 19 whose parents earn too much to qualify for Medicaid, but not enough to obtain private coverage.
Statement of Deficiency (SOD)
Summary of non-compliant findings by either a state or federal review agency. More information on Statement of Deficiency (SOD)...
State Operations Manual (SOM)
Manual providing CMS policy regarding survey and certification activities. More information on State Operations Manual (SOM)...
Statewide Planning & Research Cooperative System (SPARCS)
Data reporting system collecting patient level details on patient charateristics, dx, tx, services and charges for every hospital d/c, ambulatory surgery and ED admissions in NYS. More information on Statewide Planning & Research Cooperative System (SPARCS)...
Supplemental Security Income (SSI)
Federal income supplemental program funded by general tax revenues developed to help the aged, blind and disabled who have little or no income in order to provide food, clothing and shelter. More information on Supplemental Security Income (SSI)...
Bed that a small rural hospital can use for either skilled nursing facility or hospital acute level of care on an as needed basis if the hospital has obtained approval from the Dept. of Health and Human Services (DHHS). More information on Swing Bed...
Telecommunication Device for the Deaf (TDD)
An electronic device for text communication over a telephone line, that is designed for use by persons with hearing or speech difficulties.
Part of the Social Security Act that has statutory authority for the Medicare program. More information on Title XVIII...
Part of the Social Security Act that has statutory authority for the Medicaid program. More information on Title XIX...
Text Telephones (TTY)
A special device that lets people who are deaf, hard of hearing, or speech-impaired use the telephone to communicate.
A health care program for active duty and retired uniformed services members and their families. Formerly known as "CHAMPUS". More information on TRICARE (TRICARE)...
Unlawful practice of submitting bills piecemeal in order to maximize the reimbursement for tests/procedures that should be billed together at a lower rate.
Uniform Bill (UB)
Claims for payment are submitted to insurers on this form.
Uniform Bill Form 92 (UB-92)
An electronic format of the CMS-1450 paper claim form in general use since 1993.
Unique Physician Identification Number (UPIN)
Six-digit alpha numeric identification number used by Medicare to identify all physicians across the U.S.
United States House of Representatives
Elected to a two-year term, each representative serves the people of a specific congressional district by introducing bills and serving on committees, among other duties. More information on United States House of Representatives...
Unite Network for Organ Sharing
Non-profit organization that oversees the national database of clinical transplant information and operates the computerized organ sharing system, matching donated organs to recipients in need.
University Health System Consortium (UHC)
An alliance of 115 academic medical centers and 259 of their affiliated hospitals representing approximately 90% of the nation's non-profit academic medical centers More information on University Health System Consortium (UHC)...
Unlawful practice of using a billing code that provides a higher payment rate than the billing code that should be used for the service furnished to the patient. Major focuse of OIG enforcement.
Utilization Review Accreditation Commission (URAC)
Independent, non-profit accrediting organization related to utilization management of resources. More information on Utilization Review Accreditation Commission (URAC)...
Veteran Affairs (Deaprtment of) (VA)
Established as a Cabinet-level position on March 15, 1989. More information on Veteran Affairs (Deaprtment of) (VA)...
Provides health information, tools for managing your health, and support to those who seek information. More information on WebMD...
N/A More information on Whitehouse...
Women, Infant & Children Program (WIC)
Provides federal grants to States for supplemental food, healthcare referalls and nutritional education for low income pre/post-partum women, infants and children to age 5 found to to be at a nutritional risk. More information on Women, Infant & Children Program (WIC)...
World Health Organization (WHO)
The directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. More information on World Health Organization (WHO)...