Glossary

is a specific list of drugs. Your plan may have several tiers,and your copayment amount depends on which tier your drug is listed.Plans can choose their own tiers, so members should refer to their benefit booklet or contact the plan for more information.

Is the collection of information from the medical record via hard copy or electronic instrument.

A range of the following improper behaviors or billing practices including, but not limited to:

• Billing for a non-covered service;
• Misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered); or
• Inappropriately allocating costs on a cost report

When another person does something on purpose that causes you mental or physical harm or pain.

Your ability to get needed medical care and services.

Your ability to get medical care and services when you need them.

A separate housing arrangement within a single-family home. The ADU is a complete living unit and includes a private kitchen and bath.

An evaluative process in which a healthcare organization undergoes an examination of its policies, procedures and performance by an external organization ("accrediting body") to ensure that it is meeting predetermined criteria. It usually involves both on- and off-site surveys.

The duration of CMS's recognition of the validity of an accrediting organization's determination that a Medicare + Choice organization (M+CO) is "fully accredited".

Some States use the findings of private accreditation organizations, in part or in whole, to supplement or substitute for State oversight of some quality related standards. This is referred to as "deemed compliance" with a standard.