Term
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Definition
| Billing the recipient for any amount not paid by Medicaid or another insurance carrier. |
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Term
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Definition
| The months during which Medicaid is sought. |
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Term
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Definition
| Low income families w/children, those who receive SSI, pregnant women & children under the FPL, qualified Medicare beneficiaries |
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Term
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Definition
| Where the health care provider bills and collects from liable third parties before sending the claim to Medicaid. |
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Term
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Definition
| A situation in which covered individuals pay a portion of the health costs such as deductibles or co-insurance. |
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Term
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Definition
| The amount left over after eliminating all items that are not considered income and applying all appropriate exclusions. |
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Term
| disproportionate share hospitals |
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Definition
| Facilities that receive additional payments to ensure that communities have access to certai high-cost services such as trauma & ER services. |
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Term
| dual coverage (Medi-Medi), dual eligibles |
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Definition
| Have Medicare and Medicaid coverage. |
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Term
| Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program |
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Definition
| Developed to fit the standards of pediatric care and to meet the special physical, emotional, and developmental needs of low-income children. |
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Term
| federal poverty level (FPL) |
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Definition
| Guidelines that serve as one of the indicators for determining eligibility for many federal and state programs. |
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Term
| fiscal intermediary (FI) (fiscal agent) |
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Definition
| A commercial insurer contracted by the Department of Health & Human Services for the purpose of processing and administering claims. |
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Term
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Definition
| Basic services that must be offered to the categorically needy population in any state program. |
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Term
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Definition
| Combination federal & state medical assistance program designed to provide comprehensive medical for low-income and disabled. |
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Term
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Definition
| When a patient has Medicaid coverage and no secondary insurance. |
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Term
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Definition
| When a procedure or service is consistent with the diagnosis. |
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Term
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Definition
| Individuals who have large medical expenses and might qualify for Medicare categorically, but their income is to high. |
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Term
| Medicare-Medicaid crossover claims |
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Definition
| When a patient has Medicare and Medicaid. Medicare is first submitted to Medicare which pays its share then "crosses it over" to Medicaid. |
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Term
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Definition
| State can provides as many or as few of these services as they choose. |
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Term
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Definition
| When the state Medicaid agency payst the medical bills and then attempts to recover these paid funds from liable third parties. |
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Term
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Definition
| Medicaid. All other available third-party resources must meet their legal obligation to pay claims before the Medicaid program pays. |
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Term
| Program of All-Inclusive Care for the Elderly (PACE) |
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Definition
| Provides comprehensive alternative care for noninstitutionalized elderly who otherwise would be in a nursing home. |
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Term
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Definition
| When one state allows Medicaid beneficiaries from other states to be treated in its medical facilities. |
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Term
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Definition
| A document explaining how a claim was adjudicated. Also called and explanation of benefits. |
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Term
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Definition
| Occurs when private or family finances are depleted to the point where the individual family becomes eligible for Medicaid assistance. |
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Term
| State Children's Health INsurance Program (SCHIP) |
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Definition
| Allows states to epand their Medicaid eligibity guidelines to cover more categories of children. |
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Term
| Supplemental Security Income (SSI) |
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Definition
| Provides federally funded cash assistance to qualifying elderly and disabled poor. |
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Term
| Temporary Assistance for Needy Families (TANF) |
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Definition
| The federal-state cash assistance program for poor families. |
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Term
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Definition
| The legal obligation of third parties to pay all or part of the expenditures for medical assistance furnished under a state plan. |
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Term
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Definition
| How the decision was made regarding a payment. |
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Term
| advance beneficiary notice (ABN) |
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Definition
| A form a Medicare patient must sign if Medicare will not pay for a particular service. |
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Term
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Definition
| The fees Medicare permits for a partcular service or supply. |
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Term
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Definition
| An individual who has health insurance through the Medicare or Medicaid program. |
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Term
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Definition
| The duration of time during which a Medicare beneficiary is eligible for Part A benefits for services incurred in a hospital or SNF or both. |
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Term
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Definition
| Drugs or medicinal preparations obained from animal tissue or other organic sources. |
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Term
| Clinical Laboratory Improvement Act (CLIA) |
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Definition
| Established in 1988 to regulate quality standards for all lab testing don on humans to ensure the safety, accuracy, reliability, and timeliness of patient rest results. |
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Term
| coordination of benefits contractor |
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Definition
| This individual assumes responsibility for nearl all initial MSP development activities formerly performed by Medicare intermediaries and carriers. |
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Term
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Definition
| For a service to be covered it must be medically necessary. |
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Term
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Definition
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Term
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Definition
| The process of matching one set of data elements to their equivalents. |
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Term
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Definition
| Under Medicare, a beneficiary, on receiving notification of noncoverage, has the right to request that a FI review that determination. |
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Term
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Definition
| An explanation that an insurance carrier does not cover a certain item or service. |
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Term
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Definition
| Reporting lower level Evaluation & Management Medicare codes on claims. |
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Term
| electronic funds transfer (EFT) |
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Definition
| Payments that are automatically deposited to a provider's designated bank. |
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Term
| electronic Medicare Summary Notice |
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Definition
| Allows beneficiaries to look at their electronic MSN online. |
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Term
| Federal Insurance Contributions Act |
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Definition
| Provides for a federal sysem of old age, survivors, disabiity, and horpital insurance. |
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Term
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Definition
| An approved list of physicians, hospitals, and other providers. |
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Term
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Definition
| The 6-month period when a person can enroll in Medicare after turning 65 where federal law forbids insurance companies from denying eligibility for Medigap policies. |
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Term
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Definition
| When a member of an HMO can see a specialist without going through a PCP first. |
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Term
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Definition
| A comprehensive federal insurance program established by Congress in 1966. |
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Term
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Definition
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Term
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Definition
| Fatigue, fracture, or injury |
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Term
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Definition
| These codes are used to classify environmental events, circmstances, and other conditions that are the cause of injury and other adverse effects. |
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Term
| International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) |
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Definition
| Describes the clinical picture of each patient and provides exact information above and beyond that needed for statistics and analysis of health care trends. |
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Term
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Definition
| Terms in parentheses following the main terms. |
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Term
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Definition
| These codes are used when circumstances other than a disease or injury are recorded as a diagnosis or problem. |
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Term
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Definition
| Always printed in boldface type and include diseases, conditions, nouns, and adjectives. |
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Term
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Definition
| The presence of illness sor disease. |
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Term
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Definition
| Deaths that occur from a disease. |
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Term
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Definition
| Indented under the main term and modify the main term describing different sites, etiology, and clinical types. |
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Term
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Definition
| The cause or origin of a disease or condition. |
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