Basic Medical billing Terms

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Adjustment Correction to an incorrectly paid claim, which would result in a partial refund to Medicaid or additional payment to the provider

Adult Health Screening
A service provided to assess the health status of recipients age 21 and older in order to detect and prevent disease, disability, and other health conditions or monitor their progression.

Beneficiaries 

Persons receiving medical benefits under Medicare. Persons eligible for Medicaid are also sometimes referred to as beneficiaries

Billing Agent 
A billing agent is an entity that offers claims submission services to providers. Providers may submit claims themselves or choose to have a billing agent. Billing agents must be enrolled in the Medicaid program.

Centers for Medicare and Medicaid Services (CMS)
Formerly known as the Health Care Financing Administration (HCFA), this federal agency within the
Department of Health and Human Services is responsible for the regulation of the various states’ Medicaid programs. Also known as CMS.


Children’s Medical Services (CMS)
Children’s Medical Services is a division of the Florida Department of Health that provides children with special health care needs with a family centered, managed system of care through the CMS Network. Children with special health care needs are those children under age 21 whose serious or chronic
physical or developmental conditions require extensive preventive and maintenance care beyond that required by typically healthy children.

Child Health Check-Up
Child Health Check-Up, formerly named Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), is a comprehensive, preventive childhealth screening program. Referrals are made to other providers for treatment when indicated.

Claim A request for Medicaid to pay for health care services.

CLIA “CLIA” stands for the Clinical Laboratory Improvement Amendments of 1988.
CLIA prescribes nationwide quality assurance standards applicable to all laboratory facilities that examine materials from the human body for the  diagnosis or treatment of disease or for the assessment of health.
Concurrent Days The days when a Medicaid recipient and her newborn(s) are inpatients of the same hospital at the same time.

Cosmetic Surgery A surgical procedure for aesthetic purposes only.

Crossover Claim Medicare crossover claims are claims that have been approved for payment by Medicare and sent to Medicaid for the payment of the Medicare deductible and coinsurance within the Medicaid program limits

Deny To refuse to pay a claim as submitted.

Disease Management Organization (DMO)
Disease management organizations are private vendors who provide disease management services to Medicaid recipients enrolled in the Primary Care Case Management Program (MediPass) who have been diagnosed with certain chronic diseases, such as diabetes, HIV/AIDS, asthma, and hemophilia

Durable Medical Equipment (DME)
Equipment that can withstand repeated use, serves a medical purpose, and is appropriate for use in the recipient’s home.

Dx Code Diagnosis code as found in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).


EOMB Explanation of Medicaid or Medicare Benefits

EPSDT Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), is now named Child Health Check-Up.

Established Patient A recipient who is known to the center, office, or provider or whose records are normally available. For physicians, an established patient is an individual who has received professional services from the provider or another provider with the same specialty who belongs to the same provider group, within the past three years.

Examination A personal, face-to-face contact with a Medicaid recipient during the process of inspection or investigation inherent to the diagnosis and treatment of any disease, complaint, or disorder by a physician or persons under the direct supervision of a physician.