Glossary


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



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R

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.

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.

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.

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.

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

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

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.

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