Glossary


South Carolina Medicaid terminology: SC Web Tool, Screening Requirements, Credit Balance Reporting, Third-Party Liability, Adjustments

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A

abuse

The improper or excessive use of program benefits, resources or services by providers or beneficiaries.
Entry link: abuse

adjudication

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.
Entry link: adjudication

adjustments

Adjustments can be defined as an additional payment or a reduction in payment at the line, claim, or provider level.

Entry link: adjustments

Aid to Families with Dependent Children

(AFDC) - A federal assistance program in effect from 1935 to 1996, which was administered by the United States Department of Health and Human Services. This program provided financial assistance to children whose families had low or no income.
Entry link: Aid to Families with Dependent Children

Attorney General

(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."
Entry link: Attorney General

B

beneficiary

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).
Entry link: beneficiary

biometrics

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.
Entry link: biometrics

Blue Cross/Blue Shield

(BCBS) - Health Insurance Company
Entry link: Blue Cross/Blue Shield

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.
Entry link: Bureau of Care Management and Medical Support

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 .

Entry link: Bureau of Long Term Care and Behavioral Health Services

C

Centers for Medicare & Medicaid Services

(CMS) - The Federal Agency within DHHS that runs Medicare. In addition, CMS works with the States to run the Medicaid and SCHIP programs. CMS works to make sure that the beneficiaries in these programs are able to get high-quality health care.
Entry link: Centers for Medicare & Medicaid Services

CHAMPUS

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.

Entry link: CHAMPUS

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.
Entry link: Claim Control Number

CMS-1500 Form

CMS- 1500 forms are the standard insurance form used by non-institutional providers all across the United States to process medical insurance claims. It is part of HIPAA to standardize all medical insurance billing.
Entry link: CMS-1500 Form

contractor

A person or business which provides goods or services to another entity under terms specified in a contract.

Entry link: contractor

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.
Entry link: Current Procedural Terminology

D

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.

Entry link: Department of Health and Environmental Control

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.
Entry link: Department of Health and Human Services

diagnostic codes

Diagnostic codes are used to group and identify diseases, disorders, symptoms, and medical signs, and are used to measure morbidity and mortality.
Entry link: diagnostic codes

dual eligibility

Individuals who meet the requirements and are eligible for both Medicaid and Medicare benefits are considered to be dually eligible or dual eligibility beneficiaries.
Entry link: dual eligibility

E

EFT Agreement

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.

Entry link: EFT Agreement

Electronic Data Interchange

(EDI) is the structured transmission of data between
organizations by electronic means.

Entry link: Electronic Data Interchange

Electronic Remittance Advice

(ERA) - Allows providers to receive information concerning payment in an electronic format. ERA provides details on how claims were paid or why they were denied.
Entry link: Electronic Remittance Advice

Explanation of Benefits

(EOB) - An Explanation of Benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatment and/or services were paid for on their behalf.
Entry link: Explanation of Benefits

F

Fee-For-Service

(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.
Entry link: Fee-For-Service

File Transfer Protocol

(FTP) This is the method used to send in your claims electronically.
Entry link: File Transfer Protocol

fraud

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.

Entry link: fraud

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.
Entry link: Freedom of Information Act

G

Gap Assistance Pharmacy Program for Seniors

(GAPS) will provide state pharmacy assistance to “fill the gap” for seniors’ Medicare prescription drug coverage when their drug costs reach the “doughnut hole”. The GAPS program will pay 10% of your drug costs while you are experiencing the coverage gap.
Entry link: Gap Assistance Pharmacy Program for Seniors

Grant-in-Aid

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.
Entry link: Grant-in-Aid

grievance

A grievance is a written complaint or concern, on a non-appealable issue, from a Medicaid beneficiary or a provider.

Entry link: grievance

H

Health Insurance Portability and Accountability Act

(HIPAA) is the federal law that establishes standards for the privacy and security of health information, as well as standards for electronic data interchange (EDI) of health information.
Entry link: 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.
Entry link: Health Maintenance Organization

Healthy Connections Kids

Health Connections Kids is a health insurance program for uninsured children. SC Healthy Connections Kids (SCHIP)

Entry link: Healthy Connections Kids

Home Health

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.
Entry link: Home Health

Hospice

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.
Entry link: Hospice

L

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.
Entry link: Learning Management System

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.
Entry link: Low Income Families

M

Management and Administration Reporting System

(MARS) - A significant component of the Administrative Services Program.  This MMIS (Medicaid Management Information System) subsystem creates financial reports for fiscal planning, management, control, and state/federal reporting reporting requirements.
Entry link: 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.
Entry link: Mechanized Claims Processing

Medicaid

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.
Entry link: Medicaid

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.
Entry link: Medicaid Insurance Verification Service

Medically necessary

Related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care .
Entry link: Medically necessary

Moodle

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).

Entry link: Moodle

N

National Provider Identification

(NPI) - A unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).
Entry link: 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.
Entry link: Notice of Privacy Practices

O

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.

Entry link: Optional State Supplementation

P

Primary Care Physician

(PCP) A primary care physician is a physician/medical doctor who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis.
Entry link: Primary Care Physician

Protected Health Information

(PHI) - under HIPAA includes any individually identifiable health information.  Identifiable refers not only to data that is explicitly linked to a particular individual, it also includes health information with data items which reasonably could be expected to allow individual identification.
Entry link: Protected Health Information

R

Remittance Advice

(RA) A document that describes payments that are being made (like a receipt of the payment). An RA provides details on how claims were paid or why they were denied.
Entry link: Remittance Advice

Retroactive Eligibility

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.
Entry link: Retroactive Eligibility

Ribicoff Children

Children whose family income is below 50% of the federal poverty level. Medicaid benefits provided until age 18.
Entry link: Ribicoff Children

S

South Carolina Department of Health and Human Services

(SCDHHS) - The Healthy Connections Medicaid program is administered by the South Carolina Department of Health and Human Services, who is responsible for determining beneficiary eligibility and covered services.

Entry link: South Carolina Department of Health and Human Services

State Children’s Health Insurance Program

(SCHIP) - A program designed to provide health coverage to uninsured children with incomes too high to qualify for Medicaid, but too low to afford private health insurance. SCHIP is funded through a Federal/State partnership and was enacted as part of the Balanced Budget Act of 1997.
Entry link: 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.
Entry link: Surveillance Utilization Review Subsystem

T

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.
Entry link: Tax Equity and Fiscal Responsibility Act

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.
Entry link: Third Party Liability

Trading Partner Agreement

(TPA) - An established set of expectations between two entities exchanging HIPAA related electronic transactions.  A mechanism to communicate and document interim data guidelines and requirements.
Entry link: Trading Partner Agreement

TRICARE

TRICARE (formerly CHAMPUS) is the Health Services and Support program for DoD beneficiaries.
Entry link: TRICARE

U

UB-04 Form

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.
Entry link: UB-04 Form

Uniform Resource Locator

(URL) is a Uniform Resource Identifier (URI) that specifies where an identified resource is available and the mechanism for retrieving it.
Entry link: Uniform Resource Locator

W

Web Tool

South Carolina Web-based Claims Submission Tool
Entry link: Web 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.

Entry link: Women, Infant’s and Children’s Program


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