Some plans may vary cost shares for services based on place of treatment; in effect, charging a cost for the facility in which the service is received.

Occur when the medical record contains evidence of a service that does not exist in the encounter data. This is the most common problem in partially or fully capitated plans because the provider does not need to submit an encounter in order to receive payment for the service, and therefore may have a weaker incentive to conform to data collection standards.

Occurs when the encounter data contain evidence of a service that is not documented in the patient's medical record. If we assume that the medical record contains complete information on the patients medical history, a false positive may be considered a fraudulent service. In a fully capitated environment, however, the provider would receive no additional reimbursement for the submission of a false positive encounter.

Federal tax revenues (principally individual and business income taxes) not earmarked for a particular use.

Medicare's share of FICA is used to fund the HI Trust Fund. In FY 1995, employers and employees each contributed 1.45 percent of taxable wages, with no limitations, to the HI Trust Fund.

Provision authorizing taxes on the wages of employed persons to provide for the OASDI and HI programs. Covered workers and their employers pay the tax in equal amounts.

A program to identify management inefficiencies and areas vulnerable to fraud and abuse and to correct such weaknesses with improved internal controls.

The portion of the Medicaid program, which is paid by the Federal government.

The "Federal Register" s the official daily publication for rules, proposed
rules and notices of federal agencies and organizations, as well as Executive
Orders and other Presidential documents.

A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general supervision of a physician.

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.

A complete listing of fees used by health plans to pay doctors or other providers.

A plan or PCCM is paid for providing services to enrollees solely through fee-for-service payments plus in most cases, a case management fee.

A specified period of time in which SMI-recognized fees pertain. The fee-screen year period has changed over the history of the program.

Data regarding the financial the status of managed care entities (e.g. the medical loss ratio).

Provisions of the Railroad Retirement Act providing for transfers between the trust funds and the Social Security Equivalent Benefit Account of the Railroad Retirement program in order to place each trust fund in the same position as if railroad employment had always been covered under Social Security.

The First Responder uses a limited amount of equipment to perform initial assessment and intervention and is trained to assist other Emergency Medical Services (EMS)providers. Example: At the scene of a cardiac arrest, the First Responder would be expected to notify EMS (if not already notified) and initiate CPR with an oral airway and a barrier device.

The First Responder uses a limited amount of equipment to perform initial assessment and intervention and is trained to assist other Emergency Medical Services (EMS)providers. Example: At the scene of a cardiac arrest, the First Responder would be expected to notify EMS (if not already notified) and initiate CPR with an oral airway and a barrier device.

A private company that has a contract with Medicare to pay Part A and some Part B bills. (Also called "Intermediary.")

For Medicare, a year-long period that runs from October 1st through September 30th of the next year. The government and some insurance companies follow a budget that is planned for a fiscal year.

The net worth of facilities and other resources.

This term usually refers to a file that consists of a series of fixed-length records that include some sort of record type code.

State required studies that examine a specific aspect of health care (such as prenatal care) for a defined point in time. These projects are usually based on information extracted from medical records or MCO/PHP administrative data such as enrollment files and encounter /claims data. State staff, EQRO staff, MCO/PHP staff or more than one of these entities may perform such studies at the discretion of the State.

Under HIPAA, this is those data elements that provide or control the enveloping or hierarchical structure, or assist in identifying data content of, a transaction.

A list of certain drugs and their proper dosages. In some Medicare health plans, doctors must order or use only drugs listed on the health plan's formulary.

Listing of prescription medications which are approved for use and/or coverage by the plan and which will be dispensed through participating pharmacies to covered enrollees.

The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s).

Fraud: To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse: Payment for items or services that are billed by mistake by providers, but should not be paid for by Medicare. This is not the same as fraud.

A period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled. If you cancel, you will get your money back.

A provision that any person has a right, enforceable in court, of access of
federal agency records, except to the extent that such records, or portions
thereof, are protected from disclosure by one of nine exemptions or by one
of three special law enforcement record exclusions.

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.

An exhaustive list of possible outcomes for a variable, and the associated probability of each outcome. The sum of the probabilities of all possible outcomes from a frequency distribution is 100 percent.

The plan or Primary Care Case Manager is paid for providing services to enrollees through a combination of capitation and fee for service reimbursements.

A plan is paid for providing services to enrollees solely through capitation.

For the purposes of this umbrella SOW, a full PSC is one that performs all of the fundamental activities contained in Section 3, General Requirements, under a Task Order.

Designation that all the elements within all the accreditation standards for which the accreditation organization has been approved by CMS have been surveyed and fully met or have otherwise been determined to be acceptable without significant adverse findings, recommendations, required actions or corrective actions.