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The improper or excessive use of program benefits, resources or services by providers or beneficiaries.
Claims adjudication in health insurance refers to the determination of the insurer's payment or financial responsibility, after the member's insurance benefits are applied to a medical claim.
Adjustments can be defined as an additional payment or a reduction in payment at the line, claim, or provider level.
Aid to Families with Dependent Children
(AG) - The Attorney General is South Carolina's Chief Criminal Prosecutor, Chief Legal Officer and Securities Commissioner. The South Carolina Constitution defines the Attorney General's role as "chief prosecuting officer of the State with authority to supervise the prosecution of all criminal cases in courts of record."
A beneficiary is an enrollee who receives a Medicaid-covered service or (beginning 1998) has a managed care or private health insurance premium paid on his/her behalf (an alternate reference to recipient).
Biometrics is the science and technology of measuring and analyzing biological data. In information technology, biometrics refers to technologies that measure and analyze human body characteristics such as DNA, fingerprints, eye retinas and irises, voice patterns, facial patterns and hand measurements for authentication purposes.
Blue Cross/Blue Shield
(BCBS) - Health Insurance Company
Bureau of Care Management and Medical Support
The Bureau of Care Management and Medical Support Services is responsible for the oversight of Managed Care Organizations, Managed Care Beneficiary Enrollment, Medical Support Services that enhance direct care, School-Based and Private Rehabilitative Services, Dental, and Transportation Services.
Bureau of Long Term Care and Behavioral Health Services
The Bureau of Long Term Care and Behavioral Health Services is responsible for all long term care programs, both institutional and community based, for the elderly and other special needs populations .
Centers for Medicare & Medicaid Services
The former health care program established to provide health coverage for active duty family members and retirees and their family members. TRICARE was organized as a separate office under the Assistant Secretary of Defense and replaced CHAMPUS in 1994. Benefits covered under CHAMPUS are now covered under TRICARE.
Claim Control Number
(CCN) is a unique control number assigned by a provider/carrier to a non-institutional claim. This field links each line item with its respective claim.
A person or business which provides goods or services to another entity under terms specified in a contract.
Current Procedural Terminology
(CPT) - A systematic listing and coding of procedures and services performed by physicians. Each procedure or service is identified with a five-digit code. The use of CPT codes simplifies the reporting of services. With this coding and recording system, the procedure or service rendered by the physician is accurately identified.
Department of Health and Environmental Control
The South Carolina Department of Health and Environmental Control (DHEC) is the state agency charged with protecting public health, coastal resources, and the state’s land, air and water quality as authorized under multiple state and federal laws. Approximately 3,800 full-time DHEC employees around the state provide vital healthcare and other direct services, monitor pollution, coordinate disease control, carry out the agency’s inspection and regulatory responsibilities, respond to environmental emergencies, and protect public health and the environment in numerous other ways.
Department of Health and Human Services
(DHHS) - Administers many of the social programs of the Federal Government dealing with the health and welfare of the citizens of the U.S.
Individuals who meet the requirements and are eligible for both Medicaid and Medicare benefits are considered to be dually eligible or dual eligibility beneficiaries.
EFT (Electronic Funds Transfer) is the legal contract which covers any transfer of funds that is initiated by electronic means, such as an electronic terminal, telephone, computer, ATM, etc.
Electronic Data Interchange
(EDI) is the structured transmission of data between
Electronic Remittance Advice
Explanation of Benefits
(FFS) A system for the payment of professional services in which the practitioner is paid for the particular service rendered; separate payment to a health-care provider for each medical service rendered to a patient; a payment mechanism.
File Transfer Protocol
(FTP) This is the method used to send in your claims electronically.
An instance in which deliberate deceit is used by a provider to obtain payment for services not actually delivered or received, or by a beneficiary to claim program eligibility.
Freedom of Information Act
(FOIA) - A law that requires the U.S. Government to give out certain information to the public when it receives a written request. FOIA applies only to records of the Executive Branch of the federal government, not to those of the Congress or federal courts, and does not apply to state governments, local governments or private groups.
Gap Assistance Pharmacy Program for Seniors
A giving of federal funds to a state or local government to subsidize a public project; help provide for programs of assistance or service to the public.
A grievance is a written complaint or concern, on a non-appealable issue, from a Medicaid beneficiary or a provider.
Health Insurance Portability and Accountability Act
Health Maintenance Organization
(HMO) - Health maintenance organization. When you sign up for an HMO, you choose one doctor to coordinate all your health care. This doctor, your "primary care physician," learns your entire medical history. He or she recommends care based on knowing you from head to toe. This saves you money, as opposed to going to different specialists for different aches and pains, which costs more. If you should ever need care from a specialist, your primary care physician will refer you to one in your health plan's network. HMOs help their members receive quality care at reasonable prices.
Healthy Connections Kids
Health Connections Kids is a health insurance program for uninsured children. SC Healthy Connections Kids (SCHIP)
A facility that offers skilled nursing care and other services to patients in their homes. These include occupational, physical and speech therapies, medical social services and home health aide services.
A public agency or private organization that is primarily engaged in providing pain relief, symptom management, and supportive services to patients that are certified to be terminally ill. Medicare beneficiaries may elect to receive hospice care instead of standard Medicare benefits for terminal illnesses. Under Medicaid, beneficiaries electing hospice no longer receive Medicaid covered therapeutic service.
Learning Management System
(LMS) - A learning management system is a software application for the administration, documentation, tracking, and reporting of training programs, classroom and online events, e-learning programs, and training content.
Low Income Families
The (LIF) group includes at least one child in the home must be under age 18 or age 19 if in a secondary school. Four-month extended Medicaid individuals who lost their original LIF benefit due to increased child support. Their Medicaid benefits continue for four months after they become ineligible for LIF. Transitional Medicaid (TM) allows individuals up to 24 months of Medicaid benefits after the loss of LIF eligibility if earnings or hours of employment of the parent or caretaker relative, or loss of earned income, caused LIF ineligibility.
Management and Administration Reporting System
Mechanized Claims Processing
Mechanized claims processing and information retrieval system or system means the system of software and hardware used to process Medicaid claims from providers of medical care and services for the medical care and services furnished to recipients under the medical assistance program and to retrieve and produce service utilization and management information required by the Medicaid single state agency and federal government for program administration and audit purposes. The system consists of (1) required subsystems specified in the State Medicaid Manual (2) required changes to the required system or subsystem that are published in accordance with 433.123 of this subpart and specified in the State Medicaid Manual; and (3) approved enhancements to the system. Eligibility determination systems are not part of mechanized claims processing and information retrieval systems or enhancements to those systems.
The joint Federal/State entitlement program, enacted in 1965 as Title XIX of the Social Security Act, that pays for medical care on behalf of certain groups of low-income persons.
Medicaid Insurance Verification Service
(MIVS) - implemented and designed to give the Medicaid program information that can be used to verify or re-verify private health insurance coverage for Medicaid beneficiaries.
Moodle (abbreviation for Modular Object-Oriented Dynamic Learning Environment) is a free and open-source e-learning software platform, also known as a Course Management System, Learning Management System, or Virtual Learning Environment (VLE).
National Provider Identification
Notice of Privacy Practices
This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). It describes how we may use or disclose your protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. This notice also describes your rights to access and amend your protected health information. You have the right to approve or refuse the release of specific information outside of our system except when the release is required or authorized by law or regulation.
Optional State Supplementation
The OSS program is designed to provide a monthly payment on behalf of eligible aged, blind or disabled persons who need assistance paying the licensed/enrolled Community Residential Care Facilities where they live.
Primary Care Physician
Protected Health Information
Eligibility for Medicaid assistance for a service provided before the recipent has submitted an application. Retroactive eligibility is usually available when there is an unpaid medical bill for a service (up to three full months) immediately before the month of application for Medicaid.
Children whose family income is below 50% of the federal poverty level. Medicaid benefits provided until age 18.
South Carolina Department of Health and Human Services
State Children’s Health Insurance Program
Surveillance Utilization Review Subsystem
SURS - is a subsystem of the Medicaid Management Information System, which maintains and stores Medicaid claims data. SURS detects potential misuse of Medcaid by program recipients and providers through data analysis; provides information to facilitate investigation of fraud, waste, and abuse; and produces comprehensive reports for the utilization review staff designed to assist in analyzing quality of care and developing program policy. The SURS (Surveillance Utilization Review Subsystem) Division produces comprehensive reports that are used for the detection of Medicaid program fraud and abuse, quality of care, and the development of program policy.
Tax Equity and Fiscal Responsibility Act
(TEFRA) - The Tax Equity and Fiscal Responsibility Act Medicaid Eligibility Option, was developed to allow children with disabilities from near-poor and middle-income families to qualify for Medicaid.
Third Party Liability
Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. The Medicaid program by law is intended to be the payer of the last resort; that is, all other available third party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid.
Trading Partner Agreement
UBO4 Forms are medical insurance claim forms used by facilities such as hospitals, inpatient and outpatient clinics and ambulatory surgery centers to bill insurance companies for services rendered.
Uniform Resource Locator
South Carolina Web-based Claims Submission Tool
Women, Infant’s and Children’s Program
WIC is a Special Supplemental Food Program established by Congress in 1972, and federally funded through the United States Department of Agriculture (USDA) to assist states in safeguarding the health and nutritional well-being of our low income women, infants, and children during critical growth periods. The Department of Health and Environmental Control (DHEC) has been designated to administer the program in South Carolina.