Medical billing Terms

Glossary

ADA – American Dental Association: A professional association of dentists committed to the public’s
oral health, ethics, science and professional advancement. http://www.ada.org
AMA – American Medical Association: The American Medical Association helps doctors help
patients by uniting physicians nationwide to work on the most important professional and public
health issues. http://www.ama-assn.org
ANSI – American National Standards Institute: The Institute oversees the creation, promulgation and
use of thousands of norms and guidelines that directly impact businesses in nearly every sector.
http://www.ansi.org
API – Atypical Provider Identifier: Atypical Providers are individuals or organizations that are not
defined as healthcare providers under the National Provider Identifier (NPI) Final Rule. Atypical
providers may supply non-healthcare services such as non-emergency transportation or carpentry.
ARS – Automated Response System: A First Health Services automated system that provides access
to recipient eligibility, provider payments, claim status, prior authorization status, service limits and
prescriber IDs via the phone.
CDT – Current Dental Terminology: Current Dental Terminology (CDT) is a reference manual
published by the American Dental Association that contains a number of useful components, including
the Code on Dental Procedures and Nomenclature (Code), instructions for use of the Code, Questions
and Answers, the ADA Dental Claim Form Completion Instructions, and Tooth Numbering Systems.
http://www.ada.org/ada/prod/catalog/cdt/index.asp
CMS – Centers for Medicare and Medicaid Services: A federal entity that operates to ensure
effective, up-to-date health care coverage and to promote quality care for beneficiaries.
http://www.cms.hhs.gov
CPT – Current Procedural Terminology: CPT® was developed by the American Medical Association

in 1966. Each year, an annual publication is prepared, that makes changes corresponding with
significant updates in medical technology and practice. The 2007 version of CPT contains 8,611 codes
and descriptors. http://www.amaassn.org/ama/pub/category/3884.html
DHCFP – Division of Health Care Financing and Policy: Working in partnership with the Centers for
Medicare & Medicaid Services, the DHCFP develops policy for and oversees the administration of the
Nevada Medicaid and Nevada Check Up programs.
DME – Durable Medical Equipment: A DME provider provides medical equipment that can
withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not
useful to a person in the absence of illness or injury and is appropriate for use in the home.
DOD – Date of Decision: The date on which a recipient was determined eligible to receive Nevada
Medicaid or Nevada Check Up benefits.
EDI – Electronic Data Interchange: The transfer of data between companies by use of a computer
network. Electronic data transfers are called “transactions.” Different transactions have unique
functions in transferring health care data, e.g., eligibility requests/responses and claim submission.
EFT – Electronic Funds Transfer: EFT provides a safe, secure and efficient mode for electronic
payments and collections.
EOB – Explanation of Benefits: An EOB gives details on services provided and lists the charges paid
and owed for medical services received by an individual.
EVS – Electronic Verification System: EVS provides 24/7 online access to recipient eligibility, claim
status, prior authorization status and payments.
Glossary
FFS – Fee For Service: A payment method in which a provider is paid for each individual service
rendered to a recipient versus a set monthly fee.
HCPCS – HCFA Common Procedural Coding System: An expansion set of CPT billing codes to
account for additional services such as ambulance transport, supplies and equipment.
HIPAA – Health Insurance Portability and Accountability Act : A federal regulation that gives
recipients greater access to their own medical records and more control over how their personally
identifiable health information is used. The regulation also addresses the obligations of healthcare
providers and health plans to protect health information.
HMS – Health Management Systems: HMS works with First Health Services to perform Third Party
Liability (TPL) identification and recovery.
ICD-9 – International Classification of Diseases, 9th Revision: A listing of diagnoses and identifying
codes used by physicians for reporting diagnoses of recipients.
ICN – Internal Control Number: The 16-digit tracking number that First Health Services assigns to
each claim as it is received.
MCO – Managed Care Organization: A health care plan in which the health care provider manages
all recipient care for a set monthly fee versus a payment method in which a provider is paid for each
individual service.
MMIS – Medicaid Management Information System: An intricate computer system programmed to
reflect and enforce Nevada Medicaid and Nevada Check Up policy for providers, recipients, claims,
pharmacy and health care management.
MSM – Medicaid Services Manual: The manual maintained by the DHCFP that contains
comprehensive State policy for all Medicaid providers and services.
NPI – National Provider Identifier: A 10-digit number that uniquely identifies all providers of health
care services, supplies and equipment.
OPAS – Online Prior Authorization System: A First Health Services web application that allows
certain provider types to request an authorization and communicate with reviewers via the Internet.
PASRR – Preadmission Screening and Resident Review: A federally mandated screening process for
recipients with a serious mentally ill and/or mentally retarded/mentally retarded related diagnosis who
apply or reside in Medicaid certified beds in a nursing facility regardless of the source of payment.
PCS – Personal Care Services: A Nevada Medicaid program that provides human assistance with
certain activities of daily living that recipients would normally do for themselves if they did not have a
disability or chronic condition. See MSM Chapter 3500 for details.
PDL – Preferred Drug List: A list of drug products typically covered by Nevada Medicaid and
Nevada Check Up. The PDL limits the number of drugs available within a therapeutic class for
purposes of drug purchasing, dispensing and/or reimbursement.
QMB – Qualified Medicare Beneficiary: A recipient who is entitled to Medicare Part A benefits, has
income of 100% Federal Poverty Level or less and resources that do not exceed twice the limit for SSI
eligibility. QMB recipients who are also eligible for full Medicaid benefits have a “QMB Plus” eligibility
status. QMB recipients not eligible for Medicaid benefits have a “QMB Only” eligibility status.
RA – Remittance Advice: A computer generated report sent to providers that explains the processing
of a claim.
TPL – Third Party Liability: An insurer or entity other than Medicaid who has financial liability for
the services provided a recipient. For example, injuries resulting from
an automobile accident or an accident in a home may be covered by auto or home owner’s insurance.
UAC – User Administration Console: A web-based registration and user management tool that allows
providers to manage user access to First Health Services’ web-based applications.

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