Medicare Terms and Acronyms

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1 Medicare Terms and Acronyms A ABN Abuse Acceptance of Assignment Active Treatment Acute Exacerbation Acute Treatment Adjudication Administrative Law Judge (ALJ) Advance Beneficiary Notification (ABN) Advantage Plan Allowed amount Anti-Kickback Statute Appeal Assignment of benefits AT Advance Beneficiary Notice: The document that must be presented to a Medicare beneficiary when the provider believes that an otherwise covered service (spinal adjustment) may not be covered today (maintenance). The patient has the right to decide whether the service will be billed to Medicare. May, directly or indirectly, result in unnecessary costs to a health care benefit program; improper payment, payment for services that fail to meet professionally recognized standards of care, or that are medically unnecessary. Abuse involves payment for items or services for which there is no legal entitlement, and the provider has knowingly or intentionally misrepresented facts to obtain payment. A physician s agreement to accept the allowed amount established by Medicare, Medicaid, or a private insurer as full payment for covered services. The patient is not billed for the difference because the agreement makes it illegal to bill the patient for the balance. The patient is still responsible for appropriate copayments, coinsurance and deductible amounts up to the allowed amount. Designated by use of the AT modifier, it s care that is considered to be medically necessary for the purpose of restoring function. A worsening. An exacerbation refers to an increase in the severity of a condition or its signs and symptoms. Condition where patient is being treated for a new injury identified by X-ray or physical exam, and the treatment is expected to result in an improvement in or an arrest to the progression of the patient s condition. The process by which a carrier processes a claim and assigns responsibility. A judge who both presides over trials and adjudicates the claims or disputes. ALJ proceedings are a tier in the Medicare appeals process. The ALJ hearing is included in the third level of Medicare appeals. Official Medicare form used to notify a patient that the otherwise covered service will likely not be covered in this instance. Also known as Medicare Part C similar to an HMO, the patient has elected to purchase the Advantage Plan instead of traditional Medicare. The maximum charge an insurance carrier/ government program covers for specific services. Allowed charges are detailed in the carrier's explanation of benefits (EOB). The federal Anti-Kickback Statute is a criminal statute prohibiting the exchange, or offer to exchange, anything of value, to induce (or reward) the referral of federal health care program business. Significant penalties may be assessed for violations of this statute. An action that can be taken if you disagree with the coverage or payment decision by Medicare or another third-party payor. An insurance company s authorization to make payments directly to physicians. Active Treatment: Modifier assigned to a CMT code. 1

2 Attestation Audit Balance Billing Beneficiary Benefit Period Bundled Service A (Con t) The reporting of activities to Medicare to establish meaningful use of electronic software. The process of reviewing patient, provider, documentation, and payment related details for healthcare services. The purpose of audits is to identify and recover improper payments to healthcare providers and ensure compliance with documentation and billing guidelines. Medicare has multiple audit programs in place as an effort to preserve the integrity of the Medicare program by detecting and preventing Medicare fraud, waste, and abuse. B Billing a patient for services not paid for by insurance. Note: Managed Care plans in which the doctor participates generally prohibit balance billing. Allowed amounts such as deductibles and co-payment are the exception. The person named in an insurance policy to receive the benefits. The patient s benefit period or benefit year is the length of time benefits are paid. Most plans run on a calendar year January through December; however, some plans run on a plan year any specified 12-month period. Service(s) that are performed and deemed by a payor to be bundled within the definition and payment criteria of another payable code. Medicare deems CPT (hot/cold packs) to be bundled, (built into or grouped) with standard covered CMT services ( ). Additional billing guidelines may apply for Medicare secondary payors. Calendar Year The term used to indicate an insurance plan is in effect from 01/01 12/31. Comprehensive Error Rate Testing. This is a program established by CMS to monitor the CERT accuracy of claim payment in the Medicare Fee-For-Service Program. When a patient's condition is not expected to significantly improve or be resolved with further treatment (e.g., an acute condition), but where continued therapy may result in Chronic Treatment some functional improvement. However, once the clinical status for the condition is stable, and additional improvement is not expected, further manipulative treatment becomes maintenance therapy and is not covered. Claim Appeal A written request to a carrier asking for a review of reimbursement or a denial. Center for Medicare and Medicaid Services: part of the Federal Department of Health and CMS Human Services (HHS) that administers Medicare and Medicaid. CMS-1500 is the standard paper claim form used by health care professionals and suppliers CMS 1500 to bill insurance carriers and Medicare. CMT Chiropractic Manipulative Treatment A percentage of total costs for which the patient is responsible. In managed care plans, this Coinsurance is often called a copayment. The physician can bill for coinsurance that was not collected at the time of service. Coordination of Benefits, used to establish the order in which claims are paid (e.g., when primary and secondary carriers coordinate benefits). Prevents duplicate payment for the Coordination of same service (e.g., if a child is covered by both parents' insurance, a primary carrier is Benefits (COB) designated to pay benefits according to the terms of the policy. The secondary plan covers any remaining charges. C 2

3 C (Con t) Co-payment (Co-Pay) CPT Codes Crosswalk Deductible Deemed Provider Diagnosis Pairing DME DMEPOS DMPO DOA DOB Date of Illness/Injury (DOI) DOS Dual Coverage DX A fixed amount paid by the patient on each visit. Insurance pays the remaining, allowable amount for services. Note: A carrier s policy may require the patient to pay one copayment for chiropractic manipulation and another for therapy. Verify and note all details to take them into consideration when you calculate the patient s financial responsibility. Current Procedural Terminology Codes that are designated to describe services rendered in the office. When placed on a CMS-1500 form, they explain the service to the insurance company representative, so payment can be made. These codes are typically 5-digits long (see the American Medical Association s (AMA) annual coding update books for the most common codes and additional information). A feature where Medicare already has patient s secondary/supplemental insurance information on file and automatically transfers the claim adjudication information to that second carrier for you. D A fixed amount of money that must be paid annually, by the patient, before insurance begins paying benefits. When a carrier processes claims as in network even though the provider is not in network. For each region treated there would be a primary diagnosis of subluxation and a secondary diagnosis of a condition in that area that is caused by the subluxation. Durable Medical Equipment. This includes, but is not limited to items/supplies such as: wheelchairs, traction equipment, canes, crutches, walkers, ventilators, oxygen, monitors, nebulizers, and many others. A healthcare provider must be properly enrolled with Medicare to provide these items. Durable Medical Equipment, prosthetics, orthotics, and supplies. A healthcare provider must be properly enrolled with the Medicare program to be eligible for billing and reimbursement of these products and supplies. Discount Medical Plan Organization. An entity that, in exchange for fees, dues, charges or other consideration, provides access for discount medical plan members to providers of medical or ancillary services and the right to receive medical or ancillary services from those participating providers at a discount. Date of Accident/Injury. More commonly referred to as DOI. Date of Birth. Date of Illness/Injury. The date of onset, incident, or injury for which a patient is presenting for care. Date of Service. The date services were rendered by a healthcare provider to a patient. When more than one insurance plan covers a patient s health care. "Coordination of benefits" is the process insurance companies follow to ensure the combined benefits from all insurance plans do not exceed 100% of the fee. Diagnosis 3

4 E EFT Evaluation and Management E/M Electronic Health Records (EHR) EIN Electronic Billing EMR EOMB Episode of Care ERA Exacerbation Exclusions Facility False Claims Act Fee Schedule Fee For Service (FFS) Final Rule Fraud Electronic Funds Transfer. The method of sending or receiving funds from one bank account to another via computer-based systems. Evaluation and Management Services, commonly known as E/M ( E&M ) includes the medical coding category for patient encounters such as new patient evaluations, established patient evaluations and patient consultations. Electronic Health Records are an individual s aggregate, electronic record of health-related information created and gathered cumulatively across more than one healthcare organization. It is managed and consulted by licensed clinicians and staff members involved with the individual's health and care. Employer Identification Number entity tax identification number. Submission of charges to an insurance company via electronic means either directly to the carrier or through a clearing house. Electronic Medical Records - An individual s electronic record of health-related information. It is created, gathered, managed, and consulted by licensed clinicians and staff members, from a single organization, involved in the individual's health and care. Explanation of Medicare Benefits. This is the same as an EOB (Explanation of Benefits) but it comes from Medicare regarding a Medicare beneficiary. Visits that comprise the entire course of treatment surrounding a patient complaint, from the first initial visit to the discharge visit. Electronic Remittance Advice the electronic version of an Explanation of Benefits. Temporary but significant deterioration in the patient condition, aka a flare up. Expenses that may not be covered under the insured's contract. The insured is required to pay for services not covered by the health plan. F Listed on the Medicare fee schedule - The fee schedule used for services rendered in a hospital or other facility when that facility is participating in billing. The False Claims Act, also called the Lincoln Law, is a federal law that imposes the liability on persons or companies, (federal contractors such as healthcare providers), who defraud governmental programs. The False Claims Act is the federal government s primary litigation tool in combating fraud against the government and government programs, such as Medicare. A price list for medical practices for services offered and the corresponding charges for those services. Fee for Service program. This is the Medicare payment model in which the Part B fee schedule is applied to each service separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. The final step of a Medicare decision making process in which proposed rules are officially agreed upon by governing parties and implemented into official guidelines. Knowingly and willfully executing, or attempting to execute, a scheme or act to defraud any healthcare benefit program. To obtain by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. 4

5 G GA Government Insurance Policies Group Insurance Policy GX GY GZ Hardship Agreement HCPCS Health and Human Services (HHS) HIPAA HITECH HMO Modifier attached to a CMT code to signify that an Advance Beneficiary Notice was signed by the patient and is in place for this service Remember it this way: Got ABN! Government-sponsored insurance coverage for eligible individuals. Federal coverage includes Medicare, Medicaid, TRICARE, or CHAMPUS/ CHAMPVA. Covers groups of people under a master contract that is generally issued to employers for the benefit of their employees. These plans usually provide greater benefits at lower premiums than individual plans. Everyone in a group contract has identical coverage. Physicals aren t required for coverage. Modifier attached to any non-cmt service where a Voluntary Advance Beneficiary Notice was issued on Medicare s official ABN form. Modifier attached to any non-cmt service billed to Medicare for the purpose of a denial. Signifies that this service is never covered by Medicare when ordered or performed by a Chiropractor and that the billing is completed at the patient s request to receive an official denial from Medicare. Remember it this way: Gee Why Don t They Pay for This! Modifier attached to a CMT code to signify that the provider failed to get an Advance Beneficiary Notice signed by the patient for this service, when an ABN was required. H A financial agreement established when a patient is unable to pay the actual fees charged or their percentage (if insured). The practice must establish a hardship policy and ensure, through verification, that the patient qualifies. Healthcare Common Procedure Coding System. The standardized coding system used primarily to identify products, supplies, and services not included in the CPT codes (e.g., ambulance services, durable medical equipment, prosthetics, orthotics, supplies, etc.). The U.S. Department of Health and Human Services (HHS) is the federal agency that oversees CMS which administers programs for Medicare, the Marketplace, Medicaid, and the Children s Health Insurance Program (CHIP). Health Insurance Portability and Accountability Act. This Act is the most comprehensive protection for patient s privacy rights in history. HIPAA controls how health care professionals use a patient s PHI. HIPAA includes Coding and Transactions Rules, Privacy Rules, and Security Rules. Health Information and Technology for Economic and Clinical Health. HITECH legislation was created to stimulate the adoption of electronic health records. A Health Maintenance Organization that provides health insurance coverage to its members through a network of participating providers, hospitals, and other healthcare providers. 5

6 I J - K ICD Codes Initial Visit In-Network/Out-of- Network Insurance Benefits ITIN Judicial Review Jurisdiction Local Coverage Determination (LCD) Limiting Charge Medicare Administrative Contractor (MAC) MACRA Maintenance Treatment Managed Care Organizations Meaningful Use International Classification of Diseases: Codes that describe a patient s diagnosis. These codes are based on the diagnosis; are typically three digits; and may have additional digits after the decimal. These codes are used to describe the condition being treated, and since insurance companies determine coverage based on the condition being treated, it s imperative to make this diagnosis as specific as possible to justify the treatment rendered. We currently use the 10 th Edition, referred to as ICD-10. First visit of a course of treatment, usually includes an E/M service. Indicates whether a provider has contracted with a health plan s network or not. The list of services paid for and the amounts paid by the insurance carrier. (e.g., the schedule of benefits may indicate the carrier only pays 80% of all medical fees for Chiropractic services, leaving the subscriber responsible for the coinsurance (the remaining 20% of the medical fees)). These plans are often referred to as 80:20 plans. Individual Taxpayer Identification Number A review by the US Supreme Court of constitutional validity of a legislative act. A Judicial Review is the fifth level in the Medicare appeals process. Medicare Administrative Contractors (MACs) are responsible for a specific defined geographic area. Each MAC area is considered a Jurisdiction. L Local Coverage Determination: Set of rules issued by a Medicare fiscal intermediary or a carrier under part A or part B, indicating whether a particular item or service is covered on an intermediary- or carrier-wide basis. The maximum amount a nonparticipating provider is allowed to charge for an unassigned service. It is 115% of the non-par allowable fee. This charge does not apply to participating providers or to nonparticipating providers when they accept assignment on a claim. M Medicare Administrative Contractor: Private health insurer that has been awarded a geographic jurisdiction to process claims and administer Medicare Part A and B medical claims or DME claims. Currently 12 for Part A and B. Currently 4 for DME. Medicare Access and CHIP Reauthorization Act of 2015: MACRA combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Medicare Electronic Health Record incentive program into one single program called MIPS. Care considered not medically reasonable or necessary and not payable under the Medicare program. Defined as care rendered to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. Organizations that manage, negotiate, and contract for health care to keep costs down. They contract with health-care providers that agree to charge fixed fees for services. The fees are set by the managed care organization or by the government agency responsible for managed care. Process where Medicare has asked providers to report their efforts to utilize electronic health records in a meaningful way. 6

7 M (Con t) Medi/Medi Medicaid Plan Medical Coverage Guidelines Medical Necessity Medicare Medicare Appeals Council Review Medicare Benefit Policy Manual Medicare Part B Medicare Physician Fee Schedule Medigap Member Services MIPS Medicare Learning Network (MLN) MMI/MCI Older or disabled patients with Medicare that cannot pay the difference between a bill and the Medicare payment may qualify for Medicare and Medicaid aka Medi/Medi. In such cases, Medicare is the primary payer and Medicaid is the secondary payer. A health benefit program designed for low-income people (people on welfare or other kinds of public assistance) who cannot pay medical bills. People with Medicaid coverage are medically indigent. Eligibility for coverage might vary from month-to-month based on the recipient's income. Medicaid is a health-cost assistance program, not an insurance program. Physicians may choose not to accept Medicaid patients. An insurance carrier s guidelines used to determine coverage decisions. Medicare s definition for chiropractic care the patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment. The manipulative services rendered must have a direct therapeutic relationship to the patient s condition and provide a reasonable expectation of recovery or improvement of function. The federal health insurance program for people who are 65 or older; certain younger people with disabilities; and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant. Medicare is divided into four parts, each offering different elements of coverage and benefits. The fourth level of the Medicare Appeals process in which a written request must be filed if the appealing party (healthcare facility/provider) disagrees with the final decisions from the previous three levels of Medicare Appeals. The official Medicare manual which defines specific guidelines for healthcare providers, facilities, covered and non-covered services and other information relating to healthcare facilities and providers. Chiropractic coverage and limitations are defined in Chapter 15 of this manual. One of the four parts of Medicare, which includes Parts A, B, C, D. Part B is the part of traditional Medicare where many fee-for-service healthcare services coverage and limitations are included. Chiropractic care is covered under traditional Medicare Part B. The Medicare Physician Fee Schedule (MPFS) is a complete listing of fees used by Medicare to identify fee maximums for reimbursement to physicians and/or other providers on a feefor-service basis. Another name for second or supplemental insurance with Medicare as primary; its intent is to fill the gap of coverage that is beyond Medicare s allowable fees. A department designed to help patients with inquiries and/or concerns that may arise. Merit-Based Incentive Payment System: MIPS is the Quality Payment Program which combines the existing Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-Based Modifier (VBM) programs. Beginning with the 2017 performance year, MIPS payment adjustments are applied to Medicare Part B payments two years following the performance year. An educational tool provided by CMS which provides education, information, and resources for the healthcare community. Maximum Medical Improvement/Maximum Chiropractic Improvement: A determination that a patient has reached maximum improvement for this condition or pre-injury status, or has reached the end of an episode of care. Any care beyond this point is not medically necessary. It becomes maintenance care and is not billable to a third-party carrier. 7

8 M (Con t) Modalities Modifier MSP MVA NCD Non-Facility Fee Non-Par Fee Non-Participating Provider NPI NPPES National Quality Standard (NQS) OATS OIG Opt Out Out of Network (OON) Overpayment Physiotherapies such as traction, ultrasound, electrical muscle stimulation, and hot or cold packs considered an excluded service under Part B Medicare when ordered or delivered by a chiropractor. A modifier is a two-digit or letter suffix added to a CPT code to modify, clarify, and better define the procedure identified by the CPT code. Its purpose is to augment and further clarify. Medicare is the Secondary Payer when the beneficiary has coverage through a group health plan, worker's compensation, or there is some other third-party liability. Certain rules and procedures apply when Medicare is secondary, rather than primary. Motor Vehicle Accident N National Coverage Determination: A United States nationwide determination of whether Medicare will pay for an item or service. The non-facility rate is the payment rate for services performed in the practice/office. The 80% coverage Medicare approves and pays for nonparticipating providers. (This is usually paid to the patient because the services are unassigned. If you accept assignment on a claim as a nonparticipating provider, this is the maximum amount you can charge the Medicare patient. You will be paid 80% of this amount by Medicare.) A healthcare provider enrolled with Medicare as Non-Participating, also known as Non-Par. Providers enrolled as Non-Par can utilize the appropriate Limiting Charge fee schedule as assigned by Medicare and determine on a case-by-case basis if the provider will Accept Assignment on Medicare claims. National Provider Identification Number: A unique 10-digit identification number issued to health care providers in the United States by CMS. National Plan and Provider Enumeration System: The system developed to assign unique provider identifiers (NPI) to rendering providers and service facilities. The National Quality Standard (NQS) is a national effort to align public- and private-sector stakeholders to achieve better healthcare for all Americans. The NQS provides policy to set national goals for the improvement of healthcare quality. O Outcomes Assessment Tools assessment forms used as a standard measurement of patient s reduced function. Office of the Inspector General from the Department of Health and Human Services: This department is assigned to assure that rules are followed regarding compliance relative to fraud and abuse in Federal health care programs (e.g., Medicare, Medicaid, Tri-Care, (formerly Champus), and sometimes the Federal Employee Health Benefits Program (FEHBP). Opt Out is a contract between a provider, beneficiary, and Medicare where the provider or beneficiary does not file a claim to Medicare. Medicare excludes some healthcare provider types from the Medicare Opt out contract. Chiropractic providers are prohibited from Opting Out of Medicare. Out of Network: An out-of-network provider is one which has not contracted with an insurance company for reimbursement at a negotiated rate. Payment by the insurer or the patient that was more than the amount due. 8

9 P Paper Claim PART Participating Provider (Par) Payer Payment Payor Payor ID PECOS PFFS PPACA PPO PQRS Preauthorization Precertification Pre-Existing Aka: the universal claim or the CMS-1500 claim form (or the CMS-1500). Practices that use paper claims must have two versions of their medical billing software: one to capture the necessary data for HIPAA-compliant electronic Medicare claims and an older version to generate CMS-1500 claims. Medicare documentation system that includes criteria required for daily visit documentation. Pain and Tenderness, Asymmetry/Misalignment, Range of Motion Abnormality, Tissue/Tone Changes. A physician or other health-care provider that participates in an insurance carrier's plan. Participating providers must write off (not charge a patient for) disallowed and/or ineligible charges (aka In-Network). (AKA Payor - These spellings are both accurate and are used interchangeably throughout KMC University documents). A person, organization, etc., that pays or is responsible for paying something. Cash, check, credit card payment, insurance payment, or money order received for professional services rendered. (AKA Payer - These spellings are both accurate and are used interchangeably throughout KMC University documents). More frequently used in legal documents, payor is used to describe a person required by law to make specific payments. Insurance carrier reference number for electronic billing. Provider Enrollment, Chain, and Ownership System (PECOS), is an electronic Medicare enrollment system through which providers and suppliers can submit Medicare enrollment applications, view and print enrollment information and update and revalidate Medicare enrollment information. A Private Fee-For-Service plan is a Medicare Advantage (MA) health plan that provides beneficiaries with Medicare benefits plus any additional benefits the company decides to provide. Beneficiaries can see any provider eligible to receive payment from Medicare who agrees to accept payment from the PFFS MA. (See Deemed Provider) Patient Protection and Affordable Care Act: A health care reform bill signed into law in March 2010, to give citizens easier access to healthcare. Changes are ongoing and are implemented over time. (AKA: Obamacare or ACA). A Preferred Provider Organization provides health insurance coverage using a group of providers, hospitals, and other healthcare providers that contract with the carrier to provide services at a discounted/contracted rate. The PPO also provides health insurance coverage for services rendered by out-of-network providers, but at a higher out-of-pocket cost to the member. Physician Quality Reporting System: A quality reporting system that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. PQRS is one component of the Quality Payment Program administered by CMS and is now part of MIPS and listed as Quality Reporting. Permissions granted by the insurance carrier that must be obtained before starting certain treatments for patients. A call to the patient's insurance carrier to find out whether the treatment, surgery, tests, or hospitalization is covered under the patient's health insurance policy. A condition the patient had prior to enrolling for insurance, which may or may not preclude coverage. 9

10 P (Con t) Primary Carrier PTAN QMB QRUR Quality Codes RAC Railroad Medicare Reconsideration Redetermination Revalidation Remittance Advice Remark Codes Resource-Based Relative Value Scale (RBRVS) Routine Visits RVU Secondary Health Insurance Social Security Act Stark Laws Statutorily Excluded When there is more than one insurance carrier, coordination of benefits rules decide which one pays first. The primary payer pays first, and the secondary payer covers the balance. Provider Transaction Access Number: a number assigned to a Medicare provider required for ID when billing inquiries are made to the carrier. Q - R Qualified Medicare Beneficiary: patient who has dual benefits through both Medicare and Medicaid who qualifies for a special program in which a provider is not allowed to collect from them more than what Medicare and Medicaid pay the provider. Quality and Resource Use Report: The QRUR includes information regarding performance on quality and cost of care measures delivered to patients. It is part of CMS s effort to move physician payment toward a system that rewards value of care over volume. QRUR analyzes performance at the Tax Identification Number (TIN) level. Codes placed on a claim form or reported electronically through EHR to report to Medicare the proper use of OATs and Pain Scales in patient case management. Recovery Audit Contractor: A program created through the Medicare Modernization Act of 2003 to identify and recover improper Medicare payments paid to healthcare providers under Medicare fee-for-service plans. Replaces traditional Medicare for some patients who qualified for coverage through employment with the railroad. Level 2 of the Medicare appeals process. A Qualified Independent Contractor (QIC) is responsible for managing this level of appeals. Level 1 of the Medicare appeals process. A redetermination is an examination of a claim by the Medicare Administrative Contractor personnel. Revalidation is a required screening process for Medicare providers/suppliers. Revalidation consists of the verification of Medicare enrollment data. Revalidation is required every 5 years for healthcare providers and every 3 years for DMEPOS suppliers. Codes on an explanation of benefits (EOB) or remittance advice explaining claim processing. A formula used to determine how much money medical providers should be paid. It is often used by Medicare and by nearly all health maintenance organizations (HMOs) in the United States. You may see RBRVS in workers compensation fee schedules. Regular or customary visits. In chiropractic or healthcare, this is generally associated with preventative, wellness, or maintenance care. Relative Value Unit: one component used to calculate the dollar value of a CPT code. When calculated against geographic indices, this unit value helps determine the appropriate fee for a code. S Insurance held by a patient where Medicare or another carrier is primary (to be billed first). Title XVIII of the Social Security Act established the regulations for the Medicare program. Federal laws governing how referrals can be made; remuneration for referrals; and referrals to entities in which the referring physician (or his/her relatives) has a financial interest. Services never covered by a payer. Statutorily excluded from benefits. 10

11 S (Con t) Subluxation Subrogation Subscriber Subsequent Visits Supplemental Health Plan Supplemental Medical Review Contractor (SMRC) Third-Party Payer Timely Filing TX UPIC UPIN Utilization Review Value-Based Modifier (VBM) Write offs ZPIC A partial dislocation: A slight misalignment of the vertebrae, regarded in chiropractic theory as the cause of many health problems. Subluxation is the primary condition treated by chiropractors. The process by which a carrier determines who is responsible for payment of claims. The person named as the principal in an insurance contract. Visits following the initial visit and between E/M visits, also known as routine office visits. Supplemental health insurance policies designed to pay in addition to a patient s comprehensive major medical coverage. An organization contracted by CMS to perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. The SMRC will evaluate medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing practices. T A health plan or other entity that agrees to carry the risk of paying for a patient's medical services. A Carrier s deadline by which you must file claims to have them processed. Claims submitted after timely filing deadline will be denied. Treatment U Unified Program Integrity Contractor: A contractor/auditor selected by CMS to conduct audits and oversee Medicare fraud, waste, and abuse efforts. Unique Provider Identification Number - replaced on claims by the NPI in June of 2007, however it still may be required for authentication. Examination of services by an outside group. A utilization review committee looks at individual cases to make sure that services were medically necessary. V W X Y - Z The Value-Based Modifier (VBM) is also known as the Value Modifier. This provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule based upon the quality of care furnished as compared to the cost of care during a performance period. Total dollar amount written off due to contractual obligations, non-covered services, bad debts, or financial agreements. Zone Program Integrity Contractor: An entity established by CMS to combat fraud, waste, and abuse in the Medicare program. One of the most aggressive audit programs Medicare has at its disposal. 11