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

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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

(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.

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."



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

(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.


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.

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.


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.

diagnostic codes

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

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.


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.

Electronic Data Interchange

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

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.

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.



(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

(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.


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

(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.

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)

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.


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

(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.

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.

Medically necessary

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


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

(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).

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

(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.

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.


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.

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.

Ribicoff Children

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

(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.

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.

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

(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.


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


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.

Uniform Resource Locator

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


Web Tool

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.

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