A-Z Glossary of Terms

See Affordable Care Act

From CMS.gov: "ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients."

See Adjusted Clinical Groups

See Accountable Care Organization

See Accountable Care Organization Realizing Equity, Access, and Community Health Model

The unique beneficiary identifiation number assigned in CMS data that was previously distributed by Acumen, LLC, as the CMS data distribution contractor. Current data releases do not use this term. The current beneficary identification number on CMS Research Identifiable Files is the CCW Beneficiary ID.

From the ResDAC website: "The AHCAH initiative, launched in November 2020 in response to the COVID-19 pandemic, allows Medicare-certified hospitals to treat patients with inpatient-level care at home."

The Medline Plus website defines myocardial infarction as "heart attack."

From Johns Hopkins: "The Johns Hopkins ACG® System is a statistically valid, case-mix methodology that allows healthcare
providers, healthcare organizations, and public-sector agencies to describe or predict a population’s
past or future healthcare utilization and costs."

From the Healthcare.gov website: "The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”)."

See Acute Hospital Care at Home

See Amyotrophic Lateral Sclerosis

From the CMS Medicare Claims Processing Manual, 100-04, ch 24, section 10.1: "An ASC for Medicare purposes is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients."

From the National Institute of Standards and Technology (NIST):  "ASCII might well be called the first computer interoperability standard. Most modern developments in the computer field, such as the Internet, would not be possible without this underlying code. To this day, all data interchanges start and end as sets of ASCII characters."

See Acute Myocardial Infarction

Relevance to the Medicare program from CMS.gov "Individuals whose disability is Amyotrophic Lateral Sclerosis (ALS) are entitled to Part A the first month they are entitled to Social Security or RRB disability cash benefits. There is no waiting period."

See Ambulatory Surgery Center 

See American Standard Code for Information Interchange

Medicare Dual Eligibles with full Medicaid benefits are automatically assigned to a Part D plan.

From the Congressional Research Service: "On May 15, 1997, the President and congressional leaders agreed to a Bipartisan Budget Agreement designed to reduce the budget deficit to zero by 2002. The agreement, subsequently included in the FY1998 Budget Resolution, provided for Medicare savings of $115 billion over the FY1998-FY2002 period." "The BBA 97 achieves the target savings by slowing the rate of growth in payments to hospitals, physicians, and other providers; and by establishing new payment methodologies for skilled nursing facilities, home health agencies, and other service categories."

From an Office of the Assistant Secretary for Planning and Evaluation (ASPE) glossary: "Eligibility grouping that traditionally has been used by CMS to classify enrollees as children, adults, aged, or disabled."

In the CMS Medicaid data variable, MAX Eligibility Group, the BOE is in position 2 of the variable.

See Balanced Budget Act 

For term definition see Lexicon for Behavioral Health and Primary Care Integration, chart on document page 48: Behavioral Health Care:  "An umbrella term for care that addresses any behavioral problems bearing on health, including mental health and substance abuse conditions, stress-linked physical symptons, patient activation and health behaviors."

For the description as applies to the Medicaid program see "Behavioral Health Services".

From the ResDAC website (includes link to code table): "The current beneficiary identification code (BIC) specifies the basis of the beneficiary's elgibility for cash payment programs, mainly Social Security. When the individual qualifies under another person's account (for example, as a spouse or child), the code identifies the type of relationship between the individual and primary beneficiary."

See CCW Beneficiary Identifier.

From the MedlinePlus definition: "An enlarged prostate is also called benign prostatic hyperplasia (BPH)."

See Behavioral Health.

See Beneficiary Identification Code.

NOTE: This term applied to CMS data that was previously distributed by Acumen, LLC, as the CMS data distribution contractor.

See Acumen Beneficiary Identifier.

See Basis of Eligibility

See Bundled Payment for Care Improvement Advanced Model

See Benign Prostatic Hyperplasia.

See Coronary Artery Bypass Graft

See Critical Access Hospital

See Cash-Assistance, Medicaid-Only, fee-for-service, beneficiaries with Disabilities

See Claim Account Number

Beneficiary grouping category used in algorithms presented in the ResDAC Medicaid workshop segment "Inter- and Intrastate Variation in Medicaid Expenditures."

See Core-Based Statistical Area

See Chronic Condition Codes

See Coordinated Care Plan

See Chronic Conditions Warehouse

From the ResDAC website: "The unique CCW identifier for a beneficiary. The CCW assigns a unique beneficiary identification number to each individual who receives Medicare and/or Medicaid, and uses that number to identify an individual's records in all CCW data files (e.g., Medicare claims, MAX claims, MDS assessment data).
This number does not change during a beneficiary's lifetime and each number is used only once.
The BENE_ID is specific to the CCW and is not applicable to any other identification system or data source."

See Centers for Disease Control and Prevention

See Chronic Illness and Disability Payment System

See Chronic Disease Score

Centers for Disease Control and Prevention

From the CMS website:"The Centers for Medicare & Medicaid Services, CMS, is part of the Department of Health and Human Services (HHS)."

See Code of Federal Regulation

Codes developed by the Chronic Conditions Warehouse to flag common chronic or potentially chronic conditions or diseases. 

Refers to the CMS contractor responsible for data distribution

From the American Journal of Epidemiology: "The Chronic Disease Score is an aggregate comorbidity measure based on current medication use. "

From the University of California, San Diego, web site: "The Chronic Illness and Disability Payment System (CDPS) is a diagnostic classification system that Medicaid programs can use to make health-based capitated payments for TANF and disabled Medicaid beneficiaries."

See Comprehensive Care for Joint Replacement

From the Social Security Administration: "The claim number is the social security number under which a claim is filed or benefits are paid."

From the CDC website, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM): "The National Center for Health Statistics (NCHS), the Federal agency responsible for use of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) in the United States, has developed a clinical modification of the classification for morbidity purposes. "

See Clinical Modification

See Centers for Medicare and Medicaid Services

The CMS1450/UB04 is a uniform billing form used by institutional providers for paper submission of claims. Details on the form and CMS instructions for completion are found in Ch 25 of the CMS Claims processing manual. For electronic submissions institutional providers use the ANSI ASC X12N 837I. CMS Medicare Learning Network, Medicare Billing: Medicare Billing: 837I and Form CMS-1450ANSI

CMS form 1500 is the uniform billing form used by professional providers for paper submission of claims. Chapter 26 of the CMS claims processing manual includes instructions for completion of this form. CMS, Medicare Learning Network, Medicare Billing: 837P and Form CMS-1500

See

Per the National Archive website: "The Code of Federal Regulations (CFR) is an annual codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the Federal Government. "

COGNOS is an IBM business intelligence software solution.

The Medicaid Statistical Information System (MSIS) data marts used COGNOS Powerplay

From the CMS Claims Processing Manual, chapter 27, section 10: "The Common Working File (CWF) is the Medicare Part A and Part B beneficiary benefits coordination and pre-payment claims validation system which uses localized databases maintained by designated contractors called ‘CWF Hosts’."

From the CMS website: "A national advanced primary care medical home model that aimed to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation." Model Status: Ended. No new data for this model after Q4 2022.

From the CMS Managed Care Manual, Chapter 1, section 20.2-Coordinated Care Plans (CCPs): "As defined at 42 CFR 422.4(a)(1), a CCP is a plan that includes a network of providers that are under contract or arrangement with the MA organization to deliver the benefit package approved by CMS."

From the US Census Bureau: "Core Based Statistical Areas (CBSAs) consist of the county or counties or equivalent entities associated with at least one core (urbanized area or urban cluster) of at least 10,000 population, plus adjacent counties having a high degree of social and economic integration with the core as measured through commuting ties with the counties associated with the core."

From the National Library of Medicine: "CABG is a technique that involves using an artery or vein from elsewhere in the body to bypass the blocked vessels, restoring adequate blood flow to the heart."

A hospital or skilled nursing facility stay that meets the requirements for Medicare coverage.

See Comprehensive Primary Care Plus Model

See Current Procedural Terminology

CMS has eight criteria for designation as a critical access hospital. Briefly stated:
"- located in a State that has established a State Medicare Rural Hospital Flexibility Program
-designated by the State as a CAH
-located in a rural area
-located either more than 35-miles from the nearest hospital
-Maintain no more than 25 inpatient beds
-Maintain an annual average length of stay of 96 hours or less per patient
-Demonstrate compliance with the CAH CoPs found at 42 CFR Part 485 subpart F
-Furnish emergency care 24/7"

From the American Medical Association website: "Use the Current Procedural Terminology (CPT®) code set to bill outpatient & office procedures."

See Common Working File

From the ResDAC website: "Each request for research identifiable data requires a data management plan that outlines the administrative, physical and technical safeguards, and incident response preparedness."

See the ResDAC website, "What you need to know before you submit your request."

From the ResDAC website: "The Research Identifiable (RIF) Data Use Agreement (DUA) is a legal agreement between CMS and a requesting organization to ensure that the requesting organization adheres to CMS privacy and security requirements and data release policies for protected health information (PHI) and/or personally identifiable information (PII)."

From the CMS website: "Date of Birth".

See Diagnostic Cost Group.

From the Merriam-Webster Dictionary: "a : the art or act of identifying a disease from its signs and symptoms
b : the decision reached by diagnosis a diagnosis of pneumonia"

From the CMS Medicare Managed Care Manual, Chapter 7, section 50: "CMS selected the Principal Inpatient Diagnostic Cost Group (PIP-DCG) model as the risk adjustment method to be implemented in 2000. This model recognizes diagnoses for which inpatient care is most frequently appropriate and which are predictive of higher future costs.
To assist managed care organizations, CMS provided for a gradual phase-in of risk adjusted payment, initially adjusting only a portion of the total payment based on the PIP-DCG methodology - and later the CMS Hierarchical Condition Category (HCC) methodology - with the remainder still adjusted under the pre-BBA method based only on demographic information."

See Durable Medical Equipment.

See Durable Medical Equipment Regional Carrier.

See Data Management Plan.

See Date of Birth.

See Chronic Illness and Disability Payment System.

See Data Privacy Safeguard Program.

See Medicare Severity Diagnosis Related Group.

See Data Use Agreement.

See Dual eligible.

From the CMS website: “Dual eligible beneficiaries” generally describes beneficiaries eligible for both Medicare and Medicaid.
The term includes beneficiaries enrolled in Medicare Part A and/or Part B and receiving full Medicaid
benefits and/or assistance with Medicare premiums or cost sharing..."

Durable Medical Equipment  meets four requirements: withstands repeat use; serves a medical purpose, not useful in absence of illness, appropriate for home use. See the CMS Claims Processing Manual, ch 20

Durable Medical Equipment Regional Carriers have been replace by the DME-MACs. From the CMS website : "The DME MACs process Medicare Durable Medical Equipment, Orthotics, and Prosthetics (DMEPOS) claims for a defined geographic area or "jurisdiction," servicing suppliers of DMEPOS. "

See Diagnosis.

From CMS, "The Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21* who are enrolled in Medicaid."

Emergency Department , see Emergency room.

See Enrollment Database.

See Frontier Community Health Integration Project Demonstration - Extension

See Employer Group Waiver Plan.

From the Merriam-Webster dictionary: "a hospital room or area staffed and equipped for the reception and treatment of persons requiring immediate medical care".

Medicare billing for emergency room services is described in the CMS Medicare Claims Processing Manual, Ch 4

From the CMS website: "This model aims to improve quality and lower costs by reducing avoidable transports to hospital Emergency Departments and unnecessary hospitalizations following those transports."

As applied to Medicare Advantage or Part C plans, from chapter 9, section 10.1,Medicare Managed Care Manual, "CMS has the statutory authority to waive or modify requirements that hinder the design of, the offering of, or the enrollment in, employer/union-sponsored Medicare Advantage (MA) plans."

As applied to the Medcare Prescription Drug program or Part D, from the Medicare Prescription Drug Benefit Manual, chapter 12, section 10.1, "CMS has statutory authority to waive or modify requirements that hinder the design of, the offering of, or the enrollment in, employer/union sponsored standalone prescription drug plans (PDPs)."

From the CMS Glossary: "Detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form. Encounter data are also sometimes referred to as "shadow claims"."

From the CMS Glossary: "Permanent kidney failure. That stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life."

From the Office of the Assistant Secretary for Planning and Evaluation (ASPE): "The Enrollment DataBase (EDB) is the Centers for Medicare & Medicaid Services's database of record for Medicare Beneficiary enrollment information. It is the authoritative source for Medicare beneficiary information, entitlement, etc. The EDB has information on all Medicare beneficiaries, including Social Security Retirement and Disability insurance Beneficiaries, End Stage Renal Disease (ESRD) beneficiaries, and Railroad Retirement Board (RRB) beneficiaries."

 A previously available CMS downloadable Public Use File. The ESPC database housed information on Medicaid and CHIP program characteristics as well as selected environmental factors that are available through other publicly available databases. The final project report is available as a PDF document.

See Enterprise Privacy Policy Engine

See Early and Periodic Screening, Diagnostic, and Treatment Service.

See Emergency room.

See Environmental Scanning and Program Characteristics.

See End Stage Renal Disease.

From CMS.gov: " This model is intended to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with ESRD, while reducing Medicare expenditures and preserving or enhancing the quality of care furnished to beneficiaries with ESRD."

From CMS.gov: " This model is intended to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with ESRD, while reducing Medicare expenditures and preserving or enhancing the quality of care furnished to beneficiaries with ESRD."

See Emergency Triage, Treat and Transport Model

See ESRD Treatment Choices Model

From the CMS Medicare Prescription Drug Benefit Manual, Chapter 3, section 40.1.4: "CMS auto-enrolls and facilitates enrollment of certain LIS beneficiaries into PDPs. “Auto-Enrollment” is the process that refers to full-benefit dual eligible individuals. “Facilitated Enrollment” is the process that refers to other LIS beneficiaries. The primary differences between the two are the populations and the enrollment effective date."

See Financial Alignment Initiative for Medicare-Medicaid Enrollees

See Frequently Asked Questions.

See Frontier Community Health Integration Project Demonstration

See Frontier Community Health Integration Project Demonstration

See United States Food and Drug Administration.

From the Code of Federal Regulation, "Federal financial participation (FFP) means the Federal Government’s share of a State’s expenditures under the Medicaid program."

From the glossary of the United States Senate: " The fiscal year is the accounting period for the federal government which begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2013 begins on October 1, 2012 and ends on September 30, 2013. "
https://www.senate.gov/reference/glossary_term/fiscal_year.htm

From Census Bureau: "Standardized system of numeric and/or alphabetic coding issued by the National Institute of Standards and Technology (NIST), an agency of the US Department of Commerce. FIPS codes are assigned for a variety of geographic entities including American Indian and Alaska Native Areas, Hawaiian home lands, congressional districts, counties, county subdivisions, metropolitan areas, places and states. The purpose in using FIPS codes is to improve the use of data and avoid unnecessary duplication and incompatibility in the collection, processing and dissemination of data. FIPS codes were discountinued by NIST in 2005, but the Census Bureau continues to maintain and issue codes for the geographic entities covered."

From the Medicaid.gov website: "The Medicaid program is jointly funded by the federal government and states. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP)."

From the Office of the Assistant Secretary for Planning and Evaluation (ASPE) web site, "The poverty guidelines are the other version of the federal poverty measure. They are issued each year in the Federal Register by the Department of Health and Human Services (HHS).  The guidelines are a simplification of the poverty thresholds for use for administrative purposes — for instance, determining financial eligibility for certain federal programs.  The poverty guidelines are sometimes loosely referred to as the “federal poverty level” (FPL), but that phrase is ambiguous and should be avoided, especially in situations (e.g., legislative or administrative) where precision is important."

From the CMS Glossary: "A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general supervision of a physician." and "Health centers that have been approved by the government for a program to give low cost health care. Medicare pays for some health services in FQHCs that are not usually covered, like preventive care. FQHCs include community health centers, tribal health clinics, migrant health services, and health centers for the homeless."

Requirements for certification and links to billing instructions are included in the Medicare Learning Network booklet

From HealthCare.gov glossary: "A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits." Within Medicare, the payment system that directly pays participating providers. Also referred to as “traditional" or "original" Medicare”.

See Federal Financial Participation.

See Fee-for-Service.

See Federal Fiscal Year.

From Chapter 4 of the CCW Medicare Administrative Data User Guide: "Health care providers often submit more than one version of a claim for a particular service because they need to revise the information on the initial claim for some reason." "The final action claim is the version of the claim where all adjustments to earlier claims have been resolved and CMS’s final action on the claim is accurately recorded."

See Federal Information Processing Standards.

See Federal Medical Assistance Percentage.

See Federal Poverty Level.

See Federally Qualified Health Center.

From the Merriam-Webster Dictionary: "document (as on a website) that provides answers to a list of typical questions that users might ask regarding a particular subject; also, a question included in such a document, a list of FAQs."

From the CMS website: "This demonstration aims to develop and test new models of integrated, coordinated health care in the most sparsely-populated rural counties with the goal of improving health outcomes and reducing Medicare expenditures."

From the CMS website: "This demonstration aims to develop and test new models of integrated, coordinated health care in the most sparsely-populated rural counties with the goal of improving health outcomes and reducing Medicare expenditures."

Group Health Organization. See Group Health Plan.

See Group Health Plan.

See Graduate Nurse Education Demonstration

From theCMS website: "Under the Graduate Nurse Education Demonstration, CMS provided reimbursements to up to five eligible hospitals for the reasonable cost of providing clinical training to advanced practice registered nursing (APRN) students added as a result of the demonstration."

From the CMS website: "Under the Graduate Nurse Education Demonstration, CMS provided reimbursements to up to five eligible hospitals for the reasonable cost of providing clinical training to advanced practice registered nursing (APRN) students added as a result of the demonstration."

From the CMS web site Glossary: "A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization."

See Prior Authorization of Non-Emergent Hyperbaric Oxygen Therapy

See High Blood Pressure.

See Home and Community Based Services.

See Hierarchical Condition Categories.

See Healthcare Common Procedure Code System.

 From The National Committee for Quality Assurance (NCQA) website: "HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service."

From the CMS Glossary:"The number assigned by the Social Security Administration to an individual identifying him/her as a Medicare beneficiary. This number is shown on the beneficiary's insurance card and is used in processing Medicare claims for that beneficiary."

The Medicare Beneficiary Identifier is replacing the HICN: "We're removing Social Security Numbers (SSNs) from all Medicare cards. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status."

From the CMS Division of Institutional Claims Processing: "Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) on which payment determinations are made under several prospective payment systems."

Per the United States Government Accountability Office website for Medicaid Requirements: "HIO are entities that: (1) pay for medical services provided to recipients in exchange for fees paid by state Medicaid agencies; and (2) assume underwriting risks."

From the Healthcare.gov glossary: "A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage."

From the CMS website:  "For Medicare and other health insurance programs to ensure that these claims are processed in an orderly and consistent manner, standardized coding systems are essential. The HCPCS Level II Code Set is one of the standard code sets used for this purpose. The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA)." "Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office."

See Health Effectiveness Data and Information Set.

See Home Health Agency.

See Home Health Value-Based Purchasing Model

See Health Insurance Claim number (Medicare).

The HCCs are used for risk adjustment in the Medicare Part C and Part D programs, as described in Ch 7 of the CMS Medicare Managed Care Manual.  The CMS Risk Adjustment website offers downloadable files for ICD to HCC code mapping and current year models.

From Medline Plus: "Blood pressure is the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure. When your heart is at rest, between beats, your blood pressure falls. This is called diastolic pressure." "140/90 or higher is high blood pressure"

See Health Insuring Organization.

See Health Insurance Prospective Payment System Codes.

See Health Maintenance Organization.

From the Medicaid.gov website for HCBS: "Home and community-based services (HCBS) provide opportunities for Medicaid beneficiaries to receive services in their own home or community rather than institutions or other isolated settings. These programs serve a variety of targeted populations groups, such as people with intellectual or developmental disabilities, physical disabilities, and/or mental illnesses."

From the Medicaid.gov website for the HCBS Waiver program: "Within broad Federal guidelines, States can develop home and community-based services waivers (HCBS Waivers) to meet the needs of people who prefer to get long-term care services and supports in their home or community, rather than in an institutional setting."

From the CMS website: "A Home Health Agency (HHA) is an agency or organization which: Is primarily engaged in providing skilled nursing services and other therapeutic services;Has policies established by a group of professionals (associated with the agency or organization), including one or more physicians and one or more registered professional nurses, to govern the services which it provides..."

The CMS Medicare Benefit Policy Manual describes the services and criteria for Medicare home health coverage.

From the CMS website: "The Outcome and ASsessment Information Set (OASIS) is a group of data elements that:  Represent core items of a comprehensive assessment for an adult home care patient; and  Form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI).The OASIS is a key component of Medicare's partnership with the home care industry to foster and monitor improved home health care outcomes and is proposed to be an integral part of the revised Conditions of Participation for Medicare-certified home health agencies (HHAs) ..."

The Medicare Benefits Policy Manual details the services covered under the hospice benefit.

See Independence At Home Demonstration

See International Classification of Diseases.

See Intermediate Care Facility.

See Initial Coverage Limit.

See Beneficiary Identification Code.

From the CMS website: "The Centers for Medicare & Medicaid Services (CMS) makes identifiable data files (IDFs) available to certain stakeholders as allowed by federal laws and regulations as well as CMS policy. IDFs contain protected health information (PHI) and/or personally identifiable information (PII) and CMS is committed to ensuring this information is protected."

CMS allows organizations to access IDFs, also known as research identifiable files (RIFs), for research purposes."

See Identifiable Data File

See Independent Diagnostic Testing Facility.

From the CMS website: Under this model, "the CMS Innovation Center works with medical practices to test the effectiveness of delivering comprehensive primary care services at home and to determine if doing so improves care for Medicare beneficiaries with multiple chronic conditions. Additionally, the Demonstration rewards health care providers that provide high quality care while reducing costs."

From the CMS Medicare Learning Network: "An IDTF is a facility that is independent both of an attending or consulting physician’s office and of a hospital."

From the CCW Part D Data User Guide: "Initial Coverage Limit for the Part D benefit; also referred to as the coverage gap".

From the CMS website: "This effort aimed to improve the quality of care for people residing in long-term care (LTC) facilities by reducing avoidable hospitalizations."

From the CMS Glossary: "Health care that you get when you are admitted to a hospital."

From the CMS website: "The Inpatient Rehabilitation Facility (IRF) Patient Assessment Instrument (PAI) is the assessment instrument IRF providers use to collect patient assessment data for quality measure calculation and payment determination in accordance with the IRF QRP. Completion of the IRF-PAI is required for each Medicare Part A fee-for-service and Medicare Part C patient discharged from an inpatient rehabilitation facility."

From the Code of Federal Regulation, 21CFR56.102: "Institutional Review Board (IRB) means any board, committee, or other group formally designated by an institution to review, to approve the initiation of, and to conduct periodic review of, biomedical research involving human subjects. The primary purpose of such review is to assure the protection of the rights and welfare of the human subjects. The term has the same meaning as the phrase institutional review committee as used in section 520(g) of the act."

From the Medicaid.gov website: "Intermediate Care Facilities for individuals with Intellectual disability (ICF/ID) is an optional Medicaid benefit that enables states to provide comprehensive and individualized health care and rehabilitation services to individuals to promote their functional status and independence. Although it is an optional benefit, all states offer it, if only as an alternative to home and community-based services waivers for individuals at the ICF/ID level of care. "

From the World Health Organization website: " ICD is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions. It is the diagnostic classification standard for all clinical and research purposes."

In relation to the Medicare/Medicaid programs, ICD-9 was replaced with the implementation of ICD-10 on Oct 1, 2015.

See  Inpatient.

See Institutional Review Board.

See Inpatient Rehabilitation Facility Patient Assessment Instrument.

From the Kaiser Family Foundation website, "Kaiser is a non-profit organization focusing on national health issues, as well as the U.S. role in global health policy. Unlike grant-making foundations, Kaiser develops and runs its own policy analysis, journalism and communications programs, sometimes in partnership with major news organizations.

We serve as a non-partisan source of facts, analysis and journalism for policymakers, the media,  the health policy community and the public. Our product is information, always provided free of charge..."

See Kidney Care Choices

See Kaiser Family Foundation.

From the CMS website: "This model helps health care providers reduce the cost and improve the quality of care for patients with late-stage chronic kidney disease and ESRD" and "aims to delay the need for dialysis and encourage kidney transplantation."

See Limited Data Set.

From the CMS Glossary: "Length of Stay."

From the CMS Medicare Benefit Policy Manual, Chapter 3, section 20.1, Counting Inpatient Days: "The number of days of care charged to a beneficiary for inpatient hospital or skilled nursing facility (SNF) care services is always in units of full days. A day begins at midnight and ends 24 hours later. The midnight-to-midnight method is to be used in counting days of care for Medicare reporting purposes even if the hospital or SNF uses a different definition of day for statistical or other purposes."

From the CMS Limited Data Set File web site: "Limited Data Set Files (LDS) are identical to the previous Beneficiary Encrypted Files, but they have been stripped of data elements that might permit identification of beneficiaries. These files contain beneficiary level health information but exclude specified direct identifiers as outlined in the Health Insurance Portability and Accountability Act (HIPAA Privacy Rule).

See Low Income Subsidy.

For Medicare: "Long-term care is a range of services and support for your personal care needs. Most long-term care isn't medical care. Instead, most long-term care is help with basic personal tasks of everyday life, sometimes called activities of daily living. Medicare doesn’t cover long-term care (also called custodial care), if that's the only care you need. Most nursing home care is custodial care."

For Medicaid: "...Long term care —health-related care and services (above the level of room and board) not available in the community, needed regularly due to a mental or physical condition. A nursing facility is one of many settings for long-term care, including or other services and supports outside of an institution, provided by Medicaid or other state agencies."

See Length of Stay.

Under the Medicare Prescription Drug Benefit, plans are required to provide assistance to certain low-income beneficiaries. For details, see Chapter 13 of the Medicare Prescription Drug Benefit Manual.

See Long Term Care.

See Medicare Advantage.

See Medicare Advantage Prescription Drug Plan.

See Medicare Administrative Contractors.

From the Office of the Assistance Secretary for Evaluation and Planning: "Eligibility grouping traditionally used by CMS to classify enrollees by the financial-related criteria by which they are eligible for Medicaid. MAS groups include cash assistance-related, medically needy, poverty-related, 1115 demonstration waiver, and other."

From the Office of the Assistance Secretary for Evaluation and Planning: "Managed care organizations (including HMOs, PPOs, and PSOs) receive a fixed amount of money per client/member per month (called a capitation), no matter how much care a member needs during that month."

See Maintenance Assistance Status.

From the CCW Medicare Data User Guide, "The CCW has always disseminated files which include data regarding Medicare enrollment." "Currently, the preferred enrollment data file is the MBSF (Master Beneficiary Summary File) that uses the CMS Common Medicare Environment (CME) Database as its source." "Like the original MBSF, the current MBSF using the CME enrollment data file contains a constellation of enrollment and other person-level variables..."

See Medicaid Analytic Extract.

From the CCW Medicaid Analytic Extract Files (MAX) User Guide, Chapter 3: "The IP file contains complete stay records for Medicaid enrollees who used inpatient hospital services."

See MAX Inpatient.

From the CCW Medicaid Analytic Extract Files (MAX) User Guide, Chapter 4: "The LT file includes institutional long-term care (LTC) records for services provided by four types of long-term care facilities: 1) mental hospitals for the aged; 2) inpatient psychiatric facilities for persons under age 21; 3) intermediate care facilities for the mentally retarded (ICF/MR); and, 4) nursing facilities (NF). These records do not include procedure codes. Note that other community-based LTC services (e.g., many home-based and personal care services) are included in the OT file."

See MAX Long Term Care.

See MAX Other Therapy File.

From the CCW Medicaid Analytic Extract Files (MAX) User Guide, Chapter 6 "wide variety of service types are included in the OT file, including physician and professional services, outpatient and clinic, DME, hospice, home health, lab/x-ray and others, which are indicated by the Type of Service codes on the claim.

The OT file contains two major types of records: 1) records for services delivered; and 2) payment records for premiums paid to three types of prepaid managed care plans (which can be identified using the type of service codes)."

From the CCW Medicaid Analytic Extract Files (MAX) User Guide, Chapter 6 "The PS (Persoanl Summary) file contains one record for every individual enrolled during the calendar year represented by the file". "The PS file contains enrollment, including waiver enrollment, demographic, and summary utilization data."

From the CCW Medicaid Analytic Extract Files (MAX) User Guide, Chapter 6, "This file contains prescribed drugs, over-the-counter drugs and other items dispensed by a free-standing pharmacy. However, there are important exceptions…"

See MAX Personal Summary File

See MAX Prescription Drug File.

See Medicaid Analytic Extract (MAX) Provider Characteristics.

See Medicare Beneficiary Database.

See Medicare Bayesian Improved Surname Geocoding

See Master Beneficiary Summary File.

See Medicare.

See Medicare Current Beneficiary Survey.

See Medicare Care Choices Model

See Medicare Care Choices Model

See Medicare Care Choices Model

See Managed Care Organization.

See Minimum Data Set.

See Maryland Total Cost of Care

From the Medicaid website: "The Medicaid Analytic eXtract (MAX) data is a set of person-level data files on Medicaid eligibility, service utilization, and payments. The MAX data are created to support research and policy analysis. The MAX data are extracted from the Medicaid Statistical Information System (MSIS)."

From the CMS website: "These data files contain useful provider information from the National Plan and Provider Enumeration System (NPPES) and state-specific provider files (when available). They can be easily linked to the provider identification numbers (provider IDs) in MAX..."

The Medicaid Enrollee Supplemental File includes two segments with Medicaid enrollee data, the National Death Index (NDI) and the Chronic Conditions Segment.

From the Medicaid.gov website: "The Medicaid Management Information System (MMIS) is an integrated group of procedures and computer processing operations (subsystems) developed at the general design level to meet principal objectives." "The objectives of this system and its enhancements include the Title XIX program control and administrative costs; service to recipients, providers, and inquiries; operations of claims control and computer capabilities; and management reporting for planning and control."

From the University of California at San Diego website: "The goals of this project were to update CDPS using recently available national Medicaid data, and to develop a combined diagnostic and pharmacy based risk adjustment model based on CDPS and MedicaidRx. The CDPS update to version 5.0, and the combined model, CDPS-Rx, were developed using data from up to 41 state Medicaid programs for years 2001-2002."

From the CMS website: "The source data for MAX has historically been the Medicaid Statistical Information System (MSIS) data reported from states to CMS."

From the Medicaid.gov website: "The Medicaid and Statistical Information System (MSIS) used by the Centers for Medicare and Medicaid Services (CMS) to gather key eligibility, enrollment, program, utilization and expenditure data for the Medicaid and Children's Health Insurance Program (CHIP) has been decommissioned and replaced by T-MSIS. "

From the CMS website: "A Medicare Medical Savings Account (MSA) plan is a type of Medicare Advantage plan that combines a high-deductible health plan with a medical savings account."

From the Medicare.gov website: "Medicare is the federal health insurance program for: People who are 65 or older; Certain younger people with disabilities; People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)."

From the CMS website: "A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries."

From the Medicare Managed Care Manual, chapter 1,  section 10: "The Balanced Budget Act of 1997 (BBA) (Public Law 105-33) established a new Part C of the Medicare program, known then as the Medicare+Choice (M+C) program, effective January 1999. As part of the M+C program, the BBA authorized CMS to contract with public or private organizations to offer a variety of health plan options for beneficiaries, including both traditional managed care plans (such as those offered by Health Maintenance Organizations (HMOs) under §1876 of the Social Security Act) and new options that were not previously authorized." "The Part C program of Medicare was renamed the Medicare Advantage (MA) Program pursuant to Title II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Public Law 108-173), which was enacted on December 8, 2003."

See "Medicare Advantage Prescription Drug Plan."

From the Medicare Prescription Drug Benefit Manual, Chapter 1, Section 10.1:  "There are a number of places in which Part D statutory provisions incorporate by reference specific sections of the Act that govern the Medicare Part C program (also known as the Medicare Advantage, or MA program, and formerly the Medicare+Choice, or M+C, program)."

From the ResDAC website: The MBISG algorithm was developed by CMS to augment existing race and ethnicity data from the Social Security Administration and produce more accurate indirect estimates of the race and ethnicity of the Medicare beneficiary population. The MBISG data includes a set of probabilities that the beneficiary is a member of six racial and ethnic groups: American Indian or Alaska Native (AI/AN), Asian American and Native Hawaiian or Other Pacific Islander (AA and NHPI), Black, Hispanic, Multiracial, or White.

From the US Health and Human Services website: "The primary purpose of this modified system is to provide CMS with a singular, authoritative, database of comprehensive enrollment data on individuals in the Medicare program to support ongoing and expanded program administration, service delivery modalities, and payment coverage options."

From the CMS website: "This model tested a new option for Medicare beneficiaries to receive supported care services from selected hospice providers, while continuing to receive services provided by other Medicare providers, including care for their terminal condition."

From the CMS website: "The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a nationally representative sample of the Medicare population, conducted by the Office of Enterprise Data and Analytics (OEDA) of the Centers for Medicare & Medicaid Services (CMS) through a contract with NORC at the University of Chicago. The central goals of the MCBS is to determine expenditures and sources of payment for all services used by Medicare beneficiaries, including co-payments, deductibles, and non-covered services; to ascertain all types of health insurance coverage and relate coverage to sources of payment; and to trace outcomes over time, such as changes in health status and spending down to Medicaid eligibility and the impacts of Medicare program changes on satisfaction with care and usual source of care."

From the Baylor University Medical Denter Proceedings journal: "The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 was enacted in November 2003 and became effective on January 1, 2006. Two major changes occurred. A prescription drug benefit is now available for seniors and younger persons with disabilities who are covered by Medicare. The managed care program, formerly known as Medicare + Choice, has been redesigned and renamed Medicare Advantage."

From the CMS web site, Parts A, B and D: "Medicare has different parts that help cover specific services: Medicare Part A (Hospital Insurance) - Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Medicare Part B (Medical Insurance) - Part B helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Medicare Part D (Prescription Drug Coverage) - Medicare prescription drug coverage is available to everyone with Medicare."

For Medicare Part C, see "Medicare Advantage".

From the CMS website: "Medicare Part B (Medical Insurance) - Part B helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. Most people pay a monthly premium for Part B."

The Medicare Part C program refers to Medicare managed care plans, also know as Medicare Advantage (MA). See "Medicare Advantage."

From the CMS website: "Medicare Part D (Prescription Drug Coverage) - Medicare prescription drug coverage is available to everyone with Medicare. To get Medicare prescription drug coverage, people must join a plan approved by Medicare that offers Medicare drug coverage. Most people pay a monthly premium for Part D."

From the ResDAC website: "The MedPAR file contains information about inpatient (IP) hospital and skilled nursing facility (SNF) stays that were covered by Medicare.  Medpar records are created by rolling up information for a single stay from individual IP and SNF claims. "

From the CMS website: "Section 1886(d) of the Act specifies that the Secretary shall establish a classification system (referred to as DRGs) for inpatient discharges and adjust payments under the IPPS (Inpatient Prospective Payment System) based on appropriate weighting factors assigned to each DRG." "Currently, cases are classified into Medicare Severity Diagnosis Related Groups (MS-DRGs) for payment under the IPPS based on the following information reported by the hospital: the principal diagnosis, up to 25 additional diagnoses, and up to 25 procedures performed during the stay."

From the ResDAC website: "This variable identifies how a beneficiary qualifies for Medicare..." This variable occurs monthly.

From the CMS website: This initiative "is designed to provide individuals dually enrolled for Medicare and Medicaid with a better care experience and to better align the financial incentives of the Medicare and Medicaid programs."

From the CCW Medicare Data User Guide, "In 2013, CCW began to offer a new data product designed for studying the Medicare and Medicaid dually enrolled population. The data files are called the Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS). They are a suite of analytical files consisting of a combination of linkable beneficiary, service and clinical condition data files. The MMLEADS beneficiary-level and service-level data files are person-level files."

From the CMS Prescription Drug Benefit Manual, Chaper 7, section 30.1 "A Part D sponsor must have established an MTMP that—Is designed to ensure that covered Part D drugs prescribed to targeted beneficiaries... are appropriately used to optimize therapeutic outcomes through improved medication use; Is designed to reduce the risk of adverse events, including adverse drug interactions, for targeted beneficiaries; May be furnished by a pharmacist or other qualified provider; and may distinguish between services in ambulatory and institutional settings."

See Medicare Provider Analysis and Review.

See Medicaid Enrollee Supplemental File.

From the CMS website: "The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes.  This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems."

See Medicare Modernization Act.

See Medicaid Management Information System.

See Medicare-Medicaid Linked Enrollee Analytic Data Source.

See Medicaid RX.

See Medicare Severity Diagnosis Related Group.

See Medical Savings Account.

See Medicare Status Code.

See Medicaid Statistical Information System.

See Medication Therapy Management.

From the US department of Health and Human Services: "NCH contains billing and utilization information on Medicare beneficiaries enrolled in hospital insurance (Part A) or medical insurance (Part B) of the Medicare program."

From the CDC website: "The National Death Index (NDI) is a centralized database of death record information on file in state vital statistics offices.  Working with these ,state offices, the National Center for Health Statistics (NCHS) established the NDI as a resource to aid epidemiologists and other health and medical investigators with their mortality ascertainment activities."

From the FDA website: "Drug products are identified and reported using a unique, three-segment number, called the National Drug Code (NDC), which serves as a universal product identifier for drugs."

From the CMS website: "The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions."

National Claims History Repository 

National Drug Code

The FDA maintains a directory of drugs, each identified by a unique number called the National Drug Code or NDC. This serves as a universal product identifier for drugs, coding labeler, product, and trade package size.

National Death Index 

See Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

Not Otherwise Specified 

From the Centers for Disease Control guidelines for ICD-10 coding: "NOS “Not otherwise specified” This abbreviation is the equivalent of unspecified."

Nurse Practioner 

National Provider Identifier

From the National Cancer Institute: "A registered nurse who has additional education and training in how to diagnose and treat disease. Nurse practitioners are licensed at the state level and certified by national nursing organizations. In cancer care, a nurse practitioner may manage the primary care of patients and their families, based on a practice agreement with a doctor. Also called advanced practice nurse, APN, and NP. " 

Old Age, Survivors, and Disability Insurance

Old Age and Survivors Insurance 

Home Health Outcome and Assessment Information Set

See Oncology Care Model

From the White House website: "The Office of Management and Budget (OMB) serves the President of the United States in overseeing the implementation of his vision across the Executive Branch. Specifically, OMB’s mission is to assist the President in meeting his policy, budget, management and regulatory objectives and to fulfill the agency’s statutory responsibilities."

From the US Department of Health and Human Services website: "Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries." "HHS OIG is the largest inspector general's office in the Federal Government, with approximately 1,600 dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs."

See Office of the Inspector General

From the Social Security Administration website, "The Old-Age and Survivors Insurance Trust Fund is a separate account in the United States Treasury. A fixed proportion (dependent on the allocation of tax rates by trust fund) of the taxes received under the Federal Insurance Contributions Act and the Self-Employment Contributions Act are deposited in the fund to the extent that such taxes are not needed immediately to pay expenses. Taxes are deposited in the fund on every business day."

From the Social Security Administration, "The OASDI program—which for most Americans means Social Security—is the largest income-maintenance program in the United States. Based on social insurance principles, the program provides monthly benefits designed to replace, in part, the loss of income due to retirement, disability, or death. Coverage is nearly universal: About 96% of the jobs in the United States are covered.Workers finance the program through a payroll tax that is levied under the Federal Insurance and Self-Employment Contri-bution Acts (FICA and SECA)."

See Office of Management and Budget

See Out of Pocket Payment

See Out-of-Pocket Threshold

See Outpatient

See Outpatient Department

See Other Therapy or Other Services File

See MAX Other Therapy. 

From the Medicare.gov website: "...will count as out-of-pocket costs which will help you get out of the coverage gap. These items aren't counted toward your out-of-pocket spending: What the drug plan pays toward the drug cost (15% of the price in 2018); What the drug plan pays toward the dispensing fee (65% of the fee in 2018)" The referenced web site includes an example.

From the CMS Prescription Drug Benefit Manual, Chapter 5, section 20.3.1: " – Defined standard coverage consists of coverage of covered Part D drugs subject to: An annual deductible: Twenty-five percent coinsurance for actual costs above the annual deductible but at or below an initial coverage limit; One hundred percent coinsurance for costs above the initial coverage limit and at or below the annual out-of-pocket threshold (also known as the coverage gap); Catastrophic coverage with nominal cost-sharing for the remainder of the coverage year once an enrollee’s costs exceed the annual out-of-pocket threshold."

From the Medicare Benefit Policy Manual, Chapter 6, Section 20.2: "A hospital outpatient is a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital or CAH."

From the CMS web site for Outpatient Hospital, "A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. Part of the Hospital providing services covered by SMI, including services in an emergency room or outpatient clinic, ambulatory surgical procedures, medical supplies such as splints, laboratory tests billed by the hospital, etc. "

See Physician Assistant

See Program for All Inclusive Care for the Elderly

See Prepaid Ambulatory Health Plan

See Pennsylvania Rural Health Model

See Medicare Part B.

See Medicare Advantage.

See Medicare Part D.

Stand-along Prescription Drug Plan; Medicare Part D Program benefit plan which is independent of any Medicare Advantage program.

See Primary Care Case Management

See Primary Care First

See Prescription Drug Event

See Part D Plan

Provider, Enrollment, Chain and Ownership System

CMS system for Medicare provider enrollment. Some data from PECOS is publicly available.

From the CMS website: "This model seeks to test whether care delivery transformation in conjunction with hospital global budgets increases rural Pennsylvanians' access to high-quality care and improves their health, while also reducing the growth of hospital expenditures across payers, including Medicare, and improving the financial viability of rural Pennsylvania hospitals to improve health outcomes of and maintain continued access to care for Pennsylvania's rural residents."

From the MACPAC website:"States typically pay managed care organizations for risk-based managed care services through fixed periodic payments for a defined package of benefits. These capitation payments are typically made on a per member per month (PMPM) basis."

From the NIH National Heart, Lung, and Blood Institute website: "Other names: Peripheral Artery Disease.: "

From the National Library of Medicine Medline Plus website: "Peripheral arterial disease (PAD) happens when there is a narrowing of the blood vessels outside of your heart. The cause of PAD is atherosclerosis."

See MAX Personal Summary file.

See Private Fee-For-Service Plan

Prepaid Health Plan 

From the CMS website: "A person who has 2 or more years of advanced training and has passed a special exam. A physician assistant works with a doctor and can do some of the things a doctor does."

See Prepaid Inpatient Health Plan

See Provider Identification Number

See Per member per month

See Provider of Service

From the National Library of Medicine, PubMed website: "Post-Traumatic Stress Disorder (PTSD): An anxiety disorder that develops in in response to one or more traumatic events such as deliberate acts of interpersonal violence, severe accidents, disasters or military action."

See Preferred Provider Organization

See Prospective Payment System

From the CMS Medicare Managed Care Manual, Chapter 1, section 20.2.2: "A PPO is a CCP (Coordinated Care Plan) plan that provides for reimbursement for all covered benefits regardless of whether the benefits are provided within the plan’s network of providers (42 CFR 422.4(a)(1)(v)(B); Section 1852(e)(3)(iv) of the Social Security Act). PPOs may be local or regional (42 CFR 422.4(a)(iii)(C))."

From the Medicaid.gov website: "Prepaid Ambulatory Health Plan (PAHP): Limited benefit package that does not include inpatient hospital or institutional services (examples: dental and transportation); Payment may be risk or non-risk."

From the CMS web site: "A prepaid managed care entity that provides less than comprehensive services on an at risk basis or one that provides any benefit package on a non-risk basis."

From the Medicaid.gov website, "Prepaid Inpatient Health Plan (PIHP): Limited benefit package that includes inpatient hospital or institutional services (example: mental health); Payment may be risk or non-risk".

From the US Food and Drug Administration website: "prescription"

From the CMS website: "Every time a beneficiary fills a prescription under Medicare Part D, a prescription drug plan sponsor must submit a summary record called the prescription drug event (PDE) data to CMS. The PDE data are not the same as individual drug claim transactions, but are summary extracts using CMS-defined standard fields."

From the Medicare Prescription Drug Benefit Manual, Chapter 1, section 20, "Prescription drug plan or PDP: Prescription drug coverage that is offered under a policy, contract, or plan that has been approved as specified in 42 CFR 423.272 and that is offered by a PDP sponsor that has a contract with CMS that meets the contract requirements under subpart K of 42 CFR 423."

From the Medicaid.gov website: "Primary Care Case Management (PCCM): Primary care case managers contract with the state to furnish case management (location, coordination, and monitoring) services; Generally, paid fee-for-service for medical services rendered plus a monthly case management fee."

From the CMS website: " This voluntary alternative five-year payment model rewards value and quality by using an innovative payment structure to support the delivery of advanced primary care."

From the CMS website: "The model establishes a prior authorization process for repetitive, scheduled non-emergent ambulance transports to reduce the utilization of services that do not comply with Medicare policy while maintaining or improving quality of care."

From the CMS website: "The model establishes a prior authorization process for repetitive, scheduled non-emergent ambulance transports to reduce the utilization of services that do not comply with Medicare policy while maintaining or improving quality of care."

From the CMS website: "A Private Fee-For-Service (PFFS) plan is a Medicare Advantage (MA) health plan, offered by a State licensed risk bearing entity, which has a yearly contract with the Centers for Medicare & Medicaid Services (CMS) to provide beneficiaries with all their Medicare benefits, plus any additional benefits the company decides to provide. The PFFS plan: Pays providers on a fee-for-service basis without placing the providers at financial risk; Varies provider payment rates only based on the specialty or location of the provider or to increase utilization of certain preventive or screening services; Does not restrict members' choices among providers that are lawfully authorized to furnish services and accept the plan's terms and conditions of payment; and Does not permit the use of prior authorization or notification."

From the CMS website: "PACE combines medical, social, and long-term care services for frail people. PACE is available only in states that have chosen to offer it under Medicaid. To be eligible, you must: Be 55 years old, or older, Live in the service area of the PACE program, Be certified as eligible for nursing home care by the appropriate state agency , and Be able to live safely in the community. The goal of PACE is to help people stay independent and live in their community as long as possible, while getting high quality care they need."

From the CMS website: " Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups for inpatient hospital services).  CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities."

From the MedlinePlus.gov website: "A prostate-specific antigen (PSA) test is a test that measures the level of PSA in the blood. PSA is a substance made mostly by the prostate that may be found in an increased amount in the blood of men who have prostate cancer. The level of PSA may also be high in men who have an infection or inflammation of the prostate or benign prostatic hyperplasia (BPH; an enlarged, but noncancerous, prostate)."

From the CMS website: "CMS has established Internet-based Provider Enrollment, Chain and Ownership System (PECOS) as an alternative to the paper (CMS-855) enrollment process. Internet-based PECOS will allow physicians, non-physician practitioners and provider and supplier organizations to enroll, make a change in their Medicare enrollment, view their Medicare enrollment information on file with Medicare, or check on status of a Medicare enrollment application via the Internet. "

From the ResDAC website: "The identification number of the institutional provider certified by Medicare to provide services to the beneficiary. NOTE: Effective October 1, 2007 the OSCAR Provider Number has been renamed the CMS Certification Number (CCN). The name was changed to avoid confusion with the National Provider Identifier (NPI). The CCN (OSCAR Provider Number) will continue to play a critical role in verifying that a provider has been Medicare certified and for what type of services."

From the CMS website: "The POS (Provider of Services) file contains data on characteristics of hospitals and other types of healthcare facilities, including the name and address of the facility and the type of Medicare services the facility provides, among other information.  The data are collected through the Centers for Medicare & Medicaid Services (CMS) Regional Offices. The file contains an individual record for each Medicare-approved provider and is updated quarterly."

See Personal Summary File

See Prostate Specific Antigen

See Post-Traumatic Stress Disorder

From the CMS website: "The Centers for Medicare & Medicaid Services (CMS) makes certain Non-Identifiable Data Files (also known as public use files or PUFs) available for order. Non-Identifiable Data Files do not contain any protected health information (PHI) or personally identifiable information (PII). As a result, CMS has not set any restrictions on who may purchase these files and does not require requestors to sign a Data Use Agreement."

See Public Use File

See Peripheral Vascular Disease

See People with Disease

See Quality Assurance Surveillance Plan

See Qualified Disabled and Working Individuals

Qualified Individual 

See Qualified Medicare Beneficiary

From the CMS website: "Qualified Disabled and Working Individuals (QDWIs) - These individuals lost their Medicare Part A benefits due to their return to work. They are eligible to purchase Medicare Part A benefits, have income of 200% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only. FFP equals FMAP."

From the CMS website: "Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) - These individuals are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for full Medicaid." "QMBs with full Medicaid (QMB Plus) - These individuals are entitled to Medicare Part A, have income of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits."

From the CMS website: "The Centers for Medicare & Medicaid Services (CMS) has compiled a summary of overall Medicare Administrative Contractor (MAC) performance information as measured by the Quality Assurance Surveillance Plan (QASP) and Award Fee Plan (AF).  The QASP ensures that systematic quality assurance methods are used in administration of the contract and provides Government Surveillance oversight on the quality, quantity, and timeliness of contractor performance."

Qualified Working and Disabled Individual

From the US Railroad Retirement Board website: "The Railroad Retirement Board (RRB) is an independent agency in the executive branch of the Federal Government. The RRB’s primary function is to administer comprehensive retirement-survivor and unemployment-sickness benefit programs for the nation’s railroad workers and their families, under the Railroad Retirement and Railroad Unemployment Insurance Acts. As part of the retirement program, the RRB also has administrative responsibilities under the Social Security Act for certain benefit payments and railroad workers’ Medicare coverage."

See Rural Community Hospital Demonstration

Research Data Distribution Center Original contractor until 12-31-08 Acumen, LLC

From the CMS website: "Each year CMS reassigns low income beneficiaries from PDPs that are going above the regional LIS benchmark (and did not, or could, not waive a de minimis amount of premium above the benchmark), and from PDPs and MA plans that are terminating (which includes MA plans that are reducing their service areas).  These beneficiaries are reassigned into a PDP that is below the regional LIS benchmark."

From the CMS website: "The Medicare physician fee schedule pricing amounts are adjusted to reflect the variation in practice costs from area to area. A geographic practice cost index (GPCI) has been established for every Medicare payment locality for each of the three components of a procedure's relative value unit (i.e., the RVUs for work, practice expense, and malpractice). The GPCIs are applied in the calculation of a fee schedule payment amount by multiplying the RVU for each component times the GPCI for that component."

See Research Data Assistance Center

From the ResDAC website: "Established in 1996, the Research Data Assistance Center (ResDAC) is a Centers for Medicare and Medicaid Services (CMS) contractor that provides free assistance to researchers interested in the CMS data. As a CMS contractor, we provide assistance to academic, non-profit, for-profit and government researchers."

From the CMS website: "The Research Data Distribution Center (RDDC) disseminates Medicare and Medicaid data to public and private researchers." "Once the period of performance for these two contracts has ended, the plan is to solicit a new contract to combine the Medicare and Medicaid data dissemination activities of the RDDC and the CCW into a single contract with a single database." "End date 12-16-2010"

From the CMS website: "The Centers for Medicare & Medicaid Services (CMS) makes identifiable data files (IDFs) available to certain stakeholders as allowed by federal laws and regulations as well as CMS policy. IDFs contain protected health information (PHI) and/or personally identifiable information (PII) and CMS is committed to ensuring this information is protected. CMS allows organizations to access IDFs, also known as research identifiable files (RIFs), for research purposes."

From the CMS website: "Section 4432(a) of the Balanced Budget Act (BBA) of 1997 modified how payment is made for Medicare skilled nursing facility (SNF) services. Effective with cost reporting periods beginning on or after July 1, 1998, SNFs are no longer paid on a reasonable cost basis or through low volume prospectively determined rates, but rather on the basis of a prospective payment system (PPS)." "Per diem payments for each admission are case-mix adjusted using a resident classification system (Resource Utilization Groups, version IV (RUG-IV)) based on data from resident assessments (MDS 3.0) and relative weights developed from staff time data."

See Research Identifiable File

See Railroad Retirement Board

See Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport

See Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport

See Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport

See Resource Utilization Group. 

From the CMS website: This program tests "the feasibility and advisability of cost-based reimbursement for small hospitals that are too large to be Critical Access Hospitals. CMS is conducting an intensive evaluation of the demonstration, assessing the financial impact on participating hospitals, as well as the effect on health care for the populations served."

See Relative Value Units

See Prescription Drug

See Standard Analytical Files

See Substance Abuse and Mental Health Services Administration

See Statistical Analysis Software

See State Children's Health Insurance Program

See Surveillance, Epidemiology and End Results cancer registries

Social HMO (Health Maintenance Organization) 

From the Medicare.gov web site: "Skilled care is nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel. It’s health care given when you need skilled nursing or skilled therapy to treat, manage, and observe your condition, and evaluate your care."

Specified Low-income Medicare Beneficiary 

State Medicaid Research Files

See Skilled Nursing Facility.

See Special Needs Plan. 

From the CMS web site: "This demonstration project was implemented to test the concept of a social health maintenance organization (S/HMO) for acute and long-term care. An S/HMO integrates health and social services under the direct financial management of the provider of services. All services were provided by or through the S/HMO at a fixed, annual, prepaid capitation sum."

From the USA.gov website: "The Social Security Administration assigns Social Security numbers, and administers the Social Security retirement, survivors, and disability insurance programs. They also administer the Supplemental Security Income program for the aged, blind, and disabled."

From the SSA.gov web site: "Social Security Disability Insurance pays benefits to you and certain members of your family if you are "insured," meaning that you worked long enough and paid Social Security taxes."

From the Social Security Administration web site: "The use of the Social Security number (SSN) has expanded significantly since its inception in 1936. Created merely to keep track of the earnings history of U.S. workers for Social Security entitlement and benefit computation purposes, it has come to be used as a nearly universal identifier. Assigned at birth, the SSN enables government agencies to identify individuals in their records and businesses to track an individual's financial information. "

From the CMS web site: "A special needs plan (SNP) is a Medicare Advantage (MA) coordinated care plan (CCP) specifically designed to provide targeted care and limit enrollment to special needs individuals."

From the CMS web site: "Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid." "SLMBs with full Medicaid (SLMB Plus) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not in exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part B premiums and provides full Medicaid benefits."

See Statististical Package for the Social Sciences. 

Social Security Administration

Social Security Disability Insurance 

Supplemental Security Income 

Social Security Number 

From the CMS website: "LDS Standard Analytic Files (SAFs), also known as Medicare claims files, are available for each claim type (Inpatient, Outpatient, Skilled Nursing Facility, Home Health Agency, Hospice, Carrier and Durable Medical Equipment)."

From the Benefits.gov website: "The State Children’s Health Insurance Program (now referred to as CHIP, not SCHIP) was enacted with bipartisan support a decade ago as part of the Balanced Budget Act of 1997 (BBA). Together with Medicaid, CHIP has helped to reduce the rate of low-income uninsured children by expanding eligibility levels and simplifying enrollment procedures."

From the CMS web site: "CMS began producing State Medicaid Research File (SMRF) data from MSIS in the late 1980s for a small group of participating states.  The number of states for which SMRF were produced increased greatly in 1992 and continued to increase through 1998 as participation in MSIS grew.  The Balanced Budget Act (BBA) of 1997 mandated that all states report MSIS data beginning in 1999.  Along with the BBA mandate, data collection in MSIS expanded and SMRF was given a new name – MAX.  SMRF data are not available for requests."

From the SAS web site: "SAS is an integrated system of software solutions that enables you to perform the following tasks: data entry, retrieval, and management; report writing and graphics design; statistical and mathematical analysis; business forecasting and decision support; operations research and project management; applications development. Some people use many of the capabilities of the SAS System, and others use only a few."

From the IBM web site: "The IBM SPSS® software platform offers advanced statistical analysis, a vast library of machine-learning algorithms, text analysis, open-source extensibility, integration with big data and seamless deployment into applications."

From the CMS web site: "One form of prior authorization is step therapy. With step therapy, in most cases, you must first try certain less expensive drugs that have been proven effective for most people with your condition."

From the agency website: "The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities."

From the SSA.gov web site: "Supplemental Security Income (SSI) is a Federal income supplement program funded by general tax revenues (not Social Security taxes): It is designed to help aged, blind, and disabled people, who have little or no income; and It provides cash to meet basic needs for food, clothing, and shelter."

From the NIH National Cancer Institute web site: "The Surveillance, Epidemiology, and End Results (SEER) Program provides information on cancer statistics in an effort to reduce the cancer burden among the U.S. population."

See Transformed Medicaid Statistical Information System

See Temporary Assistance for Needy Families

See Transforming Clinical Practice Initiative

From HHS Office of Administration for Children and Families: "The Temporary Assistance for Needy Families (TANF) program is designed to help needy families achieve self-sufficiency. States receive block grants to design and operate programs that accomplish one of the purposes of the TANF program."

See Total Hip Replacement

From the Medicare.gov website: "Each Medicare drug plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less than a drug in a higher tier."

See Total Knee Replacement

See Type of Service

From US National Library of Medicine, Medline Plus: "Hip replacement is surgery for people with severe hip damage. The most common cause of damage is osteoarthritis. Osteoarthritis causes pain, swelling, and reduced motion in your joints."

From the US National Library of Medicine, Medline Plus: "Knee replacement is surgery for people with severe knee damage. Knee replacement can relieve pain and allow you to be more active. Your doctor may recommend it if you have knee pain and medicine and other treatments are not helping you anymore. When you have a total knee replacement, the surgeon removes damaged cartilage and bone from the surface of your knee joint and replaces them with a man-made surface of metal and plastic."

From the Medicaid.gov website: "The Transformed Medicaid Statistical Information System (T-MSIS) is a critical data and systems component of the CMS Medicaid and CHIP Business Information Solution (MACBIS)." "The Medicaid and Statistical Information System (MSIS) used by the Centers for Medicare and Medicaid Services (CMS) to gather key eligibility, enrollment, program, utilization and expenditure data for the Medicaid and Children's Health Insurance Program (CHIP) has been decommissioned and replaced by T-MSIS."

From the CMS website: "The Transforming Clinical Practice Initiative (TCPI) model was uniquely designed to support clinician practices through nationwide, collaborative, and peer-based learning networks designed to help clinicians and practices to achieve large scale health care transformation, prepare practices to successfully participate in value-based payment arrangements, including Alternative Payment Models (APMs), and improve the quality of care."

See True Out of Pocket Costs

From the Medicare Prescription Drug Benefit Manual, Chapter 5, section 30: "Not all enrollee out-of-pocket expenditures are considered incurred (or “true-out-of-pocket,” or TrOOP, expenditures) for purposes of applicability toward beneficiary spending against the annual out-of-pocket threshold described in section 20.3.1. Sections 30.1 and 30.2 provide further detail on whether certain expenditures are TrOOP-eligible or not, and Table 3 provides a summary of those discussions."

From the Medicaid Analytic Extract data dictionary: "Code indicating the Medicaid Analytic Extracts (MAX) type of service for this record"

See CMS form 1450.

Earlier version of the UB-04. See CMS form 1450.

From the CMS website: "The Unique Physician Identification Number (UPIN) Directory contains selected information on physicians, doctors of Osteopathy, limited licensed practitioners and some non physician practitioners who are enrolled in the Medicare Program." "Beginning with the 4th Quarter 2006 update, the existing records in the UPIN file will no longer be updated. New records will continue to be added through 2nd Quarter 2007, after which the UPIN file will be discontinued. The National Provider Identifier (NPI) is replacing the UPIN as the CMS provider identification number."

From the FDA website: "The Food and Drug Administration (FDA) is an agency within the U.S. Department of Health and Human Services." and "FDA is responsible for:
    Protecting the public health by assuring that foods (except for meat from livestock, poultry and some egg products which are regulated by the U.S. Department of Agriculture) are safe, wholesome, sanitary and properly labeled; ensuring that human and veterinary drugs, and vaccines and other biological products and medical devices intended for human use are safe and effective
    Protecting the public from electronic product radiation
    Assuring cosmetics and dietary supplements are safe and properly labeled
    Regulating tobacco products
    Advancing the public health by helping to speed product innovations"

See Unique Physician Identification Number

From the CCW website: "What is the CMS VRDC? (FAQ006) A: The CMS VRDC is an alternative solution for accessing and analyzing CMS data for research purposes. Historically, CMS has provided data to researchers by preparing and shipping encrypted data files on external media. The VRDC allows researchers to access and perform their own analysis and manipulation of CMS data virtually from their own workstation. The VRDC provides researchers with a secure mechanism to access timelier data in a more efficient and cost-effective manner."

See Value in Opioid Use Disorder Treatment Demonstration Program

See Virtual Research Data Center