Acronym/Word/Term | Definition/Description |
|---|---|
AAA | Area Agency on Aging - The single local agency designated by the Pennsylvania Department of Aging within each planning and service area to administer the delivery of a comprehensive and coordinated plan of social and other services and activities. |
ACCESS Card | Medical Assistance Identification Card - The Pennsylvania ACCESS card is issued to individuals for Medical Assistance benefits. The card is one of the methods that may be used by Medical Assistance providers to verify an MA consumer's eligibility for medical services through the Eligibility Verification System (see EVS). |
ADA | Americans with Disabilities Act |
ADAP | AIDS Drug Assistance Program (see SBPB) |
AIDS | Acquired Immunodeficiency Syndrome |
Alert | (Remittance Advice Alert) – a special notice that is sent to Medical Assistance providers with their remittance advices to relay various information to them (important messages, reminders about billing procedures, etc.) |
Alternate Payment Name | The name of the individual that the eligible Medical Assistance consumer has appointed to transact their benefits. |
APD | Advance Planning Document |
AUR | Automated Utilization Review |
BDCM | Bureau of Data and Claims Management |
Benefit Consultant | An individual or group that assists Medical Assistance recipients with choosing a physical health managed care plan, selecting a primary care provider, and obtaining information on behavioral health services. |
BFFSP | Bureau of Fee for Service Programs |
BH | Behavioral Health (services) – Commonly known as mental health and/or drug and alcohol services. |
BH-MCO | Behavioral Health Managed Care Organization – An entity directly operated by the county government or licensed by the Commonwealth as a Health Maintenance Organization or risk-assuming Preferred Provider Organization which manages the purchase and provision of behavioral health services. |
BMCO | Bureau of Managed Care Operations |
BPAP | Bureau of Policy, Analysis and Planning |
BPI | Bureau of Program Integrity |
Bulletin | (Medical Assistance Bulletin) – a formal mailing to Medical Assistance providers to relay various information to them (change in MA policy, change in billing procedures, fee schedule changes, etc.) Bulletin Search |
CAO | County Assistance Offices -- CAOs administers all the benefit programs, including Medical Assistance, at the local level. Department staff in these offices perform necessary functions such as determining and maintaining Medical Assistance recipient eligibility. |
Capitation | A fee the Department of Human Services pays periodically to a contractor for each Medical Assistance recipient enrolled under a contract for the provision of medical services, whether or not the Medical Assistance recipient receives services during the period covered by the fee. |
CARC | Claim Adjustment Reason Code |
CDC | Centers for Disease Control and Prevention |
CFO | Chief Financial Officer |
CFR | Code of Federal Regulations |
CHIP | Children's Health Insurance Program |
Children in Substitute Care | Children who have been adjudicated dependent or delinquent and are in the legal custody of a public agency and/or under the jurisdiction of the juvenile court, and are living outside of their homes in any of the following settings: shelter homes, foster homes, group homes, supervised independent living, residential treatment facilities, and residential child care facilities. |
CHR | Concurrent Hospital Review |
CIS | Client Information System – the Department's automated file that contains demographic and eligibility information for all Medical Assistance recipients. |
CMI | Case Mix Index - a number value score that describes the relative resource use for the average resident in each of the groups under the RUG-III classification system based on the assessed needs of the resident |
CMIC | Central Management Information Center |
CMS | Centers for Medicare and Medicaid Services |
COB | Coordination of Benefits |
COBRA | Congressional (or Consolidated) Omnibus Budget Reconciliation Act |
COLA | Cost of Living Adjustment |
Contractor | The successful bidder or its successor approved by the Department. |
CPT | (Physician's) Current Procedure Terminology |
CRF | Community Residential Facility |
CRN | Claim Reference Number – a 10-digit identification number assigned to every Medical Assistance claim or claim adjustment received by the Department for tracking purposes |
CRNP | Certified Registered Nurse Practitioner |
CSP | Community Support Program |
DAP | Disability Advocacy Program |
DEA | Drug Enforcement Agency |
Developmental Disability | Intellectual Disability is the most prevalent of a broad spectrum of developmental disabilities. The term "developmental disability" means a severe, chronic disability of an individual that is: |
DHHS | U.S. Department of Health and Human Services |
Disabled | Any person who has a physical or mental impairment that substantially limits one or more life activities (e.g. caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, learning, and working); or has a record of an impairment (has a history of, or has been misclassified as, having a mental or physical impairment) that substantially limits one or more major life activities; or is regarded as having an impairment. |
DME | Durable Medical Equipment |
DOH | Department of Health |
DOI | Department of Insurance |
DHS | Department of Human Services |
DRG | Diagnostic Related Group |
DRO | Domestic Relations Office |
DSH | Disproportionate Share |
Dual Eligible | An individual who is eligible to receive services through both Medicare and Medicaid (Medical Assistance) |
DUR | Drug Utilization Review |
EBT | Electronic Benefits Transfer |
ECM | Electronic Claims Management |
EDI | Electronic Data Interchange |
EFT | Electronic Funds Transfer |
EIN | Employer Identification Number |
EMC | Electronic Media Claims |
EMS | Emergency Medical Services |
EOMB | Explanation of Medical Benefits |
EPSDT | Early and Periodic Screening, Diagnosis and Treatment |
ER | Emergency Room |
EVS | Eligibility Verification System |
Facility MA CMI | Facility Medical Assistance Case Mix Index - the arithmetic mean CMI for MA residents in the nursing facility for whom the Department paid an MA day of care on the picture date. |
Family Planning Services | Contraceptive needs met through the provision of educational, medical, and social services. Services enable individuals voluntarily to determine family size, to space children, and to prevent or reduce the incidence of unplanned pregnancies. Services are made available without regard to marital status, age, sex, or parenthood. |
FDA | Food and Drug Administration |
FFS | Fee-for-Service – payment on a per-service basis for health care services provided to Medical Assistance recipients |
FQHC | Federally Qualified Health Center |
FY | Fiscal Year |
GA | Gross Adjustment or General Assistance (depends on context used) |
HBP | Healthy Beginnings Plus |
HC-L/C | HealthChoices Lehigh/Capital – The mandatory Medical Assistance managed care program for the counties of Adams, Berks, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and York. |
HCPCS | HCFA Common Procedure Coding System |
HC-SE | HealthChoices Southeast – The mandatory Medical Assistance managed care program in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties. |
HC-SW | HealthChoices Southwest – The mandatory Medical Assistance managed care program for Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland counties. |
HealthChoices | The name of Pennsylvania's 1915(b) waiver program to provide mandatory managed health care to Medical Assistance recipients. |
HIPAA | Health Insurance Portability and Accountability Act |
HEDIS | Healthplan Employer Data Information Set |
HIPP | Health Insurance Premium Payback |
HIV | Human Immunodeficiency Virus |
HMO | Health Maintenance Organization – A public or private organization organized under state law that is a federally-qualified health maintenance organization or meets the State Plan's definition of a health maintenance organization. |
HPE | Hewlett Packard Enterprise - the claims processing contractor for the Pennsylvania Medical Assistance Program |
ICF | Intermediate Care Facility |
ICF/MR | Intermediate Care Facility for the Mentally Retarded |
IEAP | Independent Enrollment and Assistance Program |
IEVS | Income Eligibility Verification System |
IFB | Invitation for Bid |
IGT | Intergovernmental Transfer Agreement - the formal document that executes the transfer of funds or certification of funds to the Commonwealth by another unit of government within the Commonwealth in accordance with Section 1903 of the Social Security Act (42 U.S.C.A. subsection 1396b(w)(6)(A). |
IRS | Internal Revenue Service |
IT | Information Technology |
ITB | Invitation to Bid |
JCAHO | Joint Commission for the Accreditation of Healthcare Organizations |
JDC | Juvenile Detention Center |
LAN | Local Area Network |
LIHEAP | Low Income Home Energy Assistance Program |
LTL | Long Term Living |
LTCMS | Long Term Care Management System |
MA | Medical Assistance |
MAAC | Medical Assistance Advisory Committee |
MAC | Maximum Allowed Cost |
MAID (number) | Medical Assistance Identification Number |
MAMIS | Medical Assistance Management Information System |
MAN | Metropolitan Area Network |
MCO | Managed Care Organization – An entity which manages the purchase and provision of physical or behavioral health services for eligible Medical Assistance recipients. |
MDS | Minimum Data Set - one of the three components of the federally designed Resident Assessment Instrument (RAI). The RAI includes the MDS, the Resident Assessment Protocols and Utilization Guidelines. The MDS is a minimum care of assessment items with definitions and coding categories needed to comprehensively assess a nursing facility resident. |
MEDA | Medical Eligibility Determination Automation |
MFCU | Medicaid Fraud Control Unit |
MH | Mental Health |
MMIS | Medicaid Management Information System |
MQC | Medicaid Quality Control |
MSA (group) | Metropolitan Statistical Area - a statistical standard classification designated and defined by the Federal Office of Management and Budget following a set of official published standards. |
MSI | Medical Services Invoice |
NCPDP | National Council of Prescription Drug Programs |
NCQA | National Committee for Quality Assurance |
NDC | National Drug Code |
NECS | National Electronic Claims Submission |
NF | Nursing Facility - a general nursing facility, county or hospital-based nursing facility, which is licensed by the Department of Health and enrolled in the Medical Assistance program. |
NIS | Nursing Information System - the comprehensive automated database of nursing facility, resident and fiscal information needed to operate the Pennsylvania Case-Mix Payment System. |
NPDB | National Practitioner Data Bank |
NPI | National Provider Identifier |
OBRA | Omnibus Budget Reconciliation Act |
OCDEL | Office of Child Development and Early Learning |
OCYF | Office of Children, Youth and Families |
ODP | Office of Developmental Programs |
OIM | Office of Income Maintenance |
OLTL | Office of Long Term Living |
OMAP | Office of Medical Assistance Programs |
OMD | Office of the Medical Director |
OMHSAS | Office of Mental Health and Substance Abuse Services |
OPTIONS | Community Based Long Term Care |
PA | Prior Authorization |
PACE | Pennsylvania Adoption Cooperative Effort |
PACE | Pharmaceutical Assistance Contract for the Elderly |
PACSES | Pennsylvania's Child Support Enforcement System |
PBM | Pharmacy Benefit Manager |
PCP | Primary Care Provider – A specific medical services provider responsible for providing primary care services and locating, coordinating, and monitoring other medical care and rehabilitative services on behalf of a Medical Assistance recipient. |
PDA | Pennsylvania Department of Aging |
PE | Program Exception – Exception to the normal MA fee schedule or process for various reasons. |
PERM | Payment Error Rate Measurement |
PH | Physical Health |
PHC4 | Pennsylvania Healthcare Cost Containment Council |
PH-MCO | Physical Health Managed Care Organization – A Commonwealth-licensed risk-bearing entity which has contracted with the Department of Human Services to manage the purchase and provision of physical health services to Medical Assistance recipients. |
PMS | Pennsylvania Medical Society |
POS | Point of Sale |
POSNet | Pennsylvania Open Systems Network – The network that is used to access the Department's computer system, and to send and receive files from the Department's contractors. POSNet is an extended Ethernet LAN (Local Area Network). The selection of industry standard protocols means that the LAN capabilities can be extended statewide by using LANs, Metropolitan Area Networks (MANs), and Wide Area Networks (WANs). |
PPS | Prospective Payment System - Medicare's version of our case-mix reimbursement system. |
ProDUR | Prospective Drug Utilization Review |
PROMISe™ | Provider Reimbursement Operations and Management Information System |
Provider | A person, firm, or corporation enrolled in the Pennsylvania Medical Assistance Program which provides services or supplies to Medical Assistance recipients. |
PRR | Program Revision Request |
PSR | Place of Service Review |
QA | Quality Assurance |
QC | Quality Control |
QM | Quality Management |
QMB | Qualified Medicare Beneficiary |
RA | Remittance Advice – an explanation containing the status of claims processed during a particular period for providers. Remittance Advices are mailed to providers on a weekly basis. |
Recipient | A person eligible to receive health-related services under the Medical Assistance Program in Pennsylvania. |
RetroDUR | Retrospective Drug Utilization Review |
RFP | Request for Proposal |
RIDS | Resolution Image Display System |
RNAC | Registered Nurse Assessment Coordinator - an individual licensed as a registered nurse by the State Board of Nursing and employed by a nursing facility, and who is responsible for coordinating and certifying completion of the resident assessment. |
RRP | Recipient Restriction Program |
RTF | Residential Treatment Facility |
RUG-III | Resource Utilization Group Version III - a category-based resident classification system used to classify nursing facility residents into groups based on their characteristics and clinical needs. |
SCSC | State Civil Service Commission |
SPBP | Special Pharmaceutical Benefits Program - The SPBP is a unique program that provides specific HIV/AIDS drugs and several atypical antipsychotic drugs for low and moderate income individuals with a diagnosis of HIV/AIDS or schizophrenia. Medical Assistance clients with drug benefits through the regular fee-for-service program or MA Managed Care Organizations are NOT eligible for SPBP coverage. The HIV/AIDS piece of the program is usually known as AIDS Drug Assistance Program or ADAP in other states. |
SPOC | Single Point of Contact |
SSA | Social Security Administration |
SSI | Supplemental Security Income - Persons permanently disabled (must last at least 12 months) as determined by the Social Security Administration may qualify for this. |
SSN | Social Security Number |
STD | Sexually Transmitted Disease |
SURS | Surveillance and Utilization Reporting System - a computerized reporting system used to detect potential fraud and abuse of Medical Assistance providers and recipients. |
TANF | Temporary Assistance for Needy Families |
TCM | Targeted Case Management |
TIN | Tax Identification Number |
Total Facility CMI | Total Facility Case Mix Index - the arithmetic mean case mix index of all residents regardless of the resident's sources of funding. |
TPL | Third Party Liability |
UB-92 (form) | Unified Billing 1992 (form) – used for billing Pennsylvania Medical Assistance for Inpatient services |
UMR | Utilization Management Review - an audit conducted by the Department's medical and other professional personnel to monitor the accuracy and appropriateness of payments to nursing facilities to determine the necessity for continued stay of residents. |
VT | Voucher Transmittal |
WAN | Wide Area Network |
WIC | Women, Infants and Children (program) |
YTD | Year to Date |