Health Reimbursement Arrangements (HRA)
Accounts that employers can establish for employees to reimburse a portion of their eligible family members’ out-of-pocket medical expenses, such as deductibles, coinsurance and pharmacy expenses.
health savings account (HSA)
Allows members to save money into tax-advantaged accounts. Qualified contributions made to HSAs are tax-deductible, and funds withdrawn to pay for qualified medical expenses are tax-free.
Hold Harmless Agreement
An agreement with a provider not to bill the subscriber for any difference between billed charges for covered services (excluding coinsurance) and the amount the provider has contractually agreed with a Blue Cross Blue Shield company as full payment for those services.
hospice care
A set of specialized healthcare services that provide support to terminally ill patients and their families.
managed care
The integration of financing and delivery of healthcare within a system that seeks to manage the accessibility, cost and quality of that care.
managed dental care
Any dental plan offered by an organization that provides a benefit plan that differs from a traditional fee-for-service plan.
medical advisory committee
The MCO (managed care organization) committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation and changes in authorization procedures. Medical advisory committees also review data regarding new medical technology and examine proposed medical policies.
PHI – Protected Health Information
Information that relates to an individual’s past, present, or future physical or mental health or condition, or the past, present, or future payment for the provision of health care to an individual, including demographic information, received from or on behalf of a health care provider, health plan, clearinghouse, or employer, which either identifies the individual or could be reasonably used to identify the individual. It includes such information contained in any form or medium (electronic, paper, oral, etc.).
PII – Personally Identifiable Information
An individual’s first name or first initial and last name in combination with any one, or more, of the following: (1) Social Security number; (2) driver’s license number or state identification card number; or (3) account number, credit or debit card number, in combination with any required security code, access code or password that would permit access to an individual’s financial account. PII does not include publicly available information that is lawfully made available to the general public from federal, state or local government records or widely distributed media. PII, as used in these Inter-Plan Programs Policies and Provisions, may have other meanings as assigned by various state laws related to data security breach notification.
Plan
Refers to any Blue Cross and/or Blue Shield Plan.
point-of-service (POS) plan
A type of Health Benefit Plan that allows members to go outside the network for non-emergency care, but may result in a lower level of benefits being paid by the Health Benefit Plan.
ABN Advance Beneficiary Notice of Non-coverage
ADA American Dental Association; or American Diabetes Association
AIC MA Amount in Controversy (Medicare Appeals)
ALJ Administrative Law Judge
AMA American Medical Association
ANSI American National Standards Institute
ARA Associate Regional Administrator
ASA American Society of Anesthesiologists
ASC Ambulatory Surgical Center
AWP Average Wholesale Price
BBA Balanced Budget Act (of 1997)
BL Black Lung (Coal Miners)
BNA Bureau of National Affairs
CAC Carrier Advisory Committee
CAH Critical Access Hospital
CCI refer to NCCI
CCN Correspondence Control Number
CDC CERT Documentation Contractor
CDE Certified Diabetic Educators
CERT Comprehensive Error Rate Testing
CF Conversion Factor
CFR Code of Federal Regulations
CLIA Clinical Laboratory Improvement Amendments (If you perform clinical lab tests in your office, you need a CLIA number)
CMD Contractor Medical Director
CMHC Community Mental Health Center
CMN Certificate of Medical Necessity
CMP Civil Monetary Penalty
CMPL Civil Monetary Penalty Law
CMR Comprehensive Medical Review
CMS The Centers for Medicare & Medicaid Services
CNM Certified Nurse Midwife
CNMW Certified Nurse Midwife
CNS Certified Nurse Specialist
CO Central Office (CMS, in Baltimore, MD)
COB Coordination of Benefits
COBC Coordination of Benefits Contractor
CORF Comprehensive Outpatient Rehabilitation Facility
CP Clinical Psychologist
CPO Care Plan Oversight
CPT Current Procedural Terminology (5-digit codes, all numeric; Coding manual published yearly by the AMA)
CR Change Request
CRC CERT Review Contractor
CRD Chronic Renal Disease
CRNA Certified Registered Nurse Anesthetist
C-SNAP CMS Secure Net Access Portal
CSW Clinical Social Worker
CWAG Coalition of Wisconsin Aging Group
CWF Common Working File (Medicare Part A and Part B claims history and entitlement information database)
DC Doctor of Chiropractic
DDS Doctor of Dental Surgery
DEFRA Deficit Reduction Act of 1984
DG Documentation Guidelines
DHHS Department of Health & Human Services
DHSQ Division of Health Standards and Quality
DMD Doctor of Medical Dentistry
DME Durable Medical Equipment
DME MAC Durable Medical Equipment Medicare Administrative Contractor
DMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
DO Doctor of Osteopathy
DOB Date of Birth
DOL Department of Labor (Federal Agency)
DOS Date of Service
DP Doctor of Podiatry
DPM Doctor of Podiatric Medicine
DRG Diagnostic Related Grouping
DSC Doctor of Surgical Chiropody
DSP Doctor of Surgical Podiatry
DX Diagnosis/Diagnoses
ECF Extended Care Facility
EDI Electronic Data Interchange
EEG Electroencephalogram
EFT Electronic Funds Transfer
EGHP Employer Group Health Plan
EIN Employer Identification Number (Tax ID/SSN)
EKG Electrocardiogram
E/M Evaluation and Management (visit)
EMC Electronic Media Claims
EOB Explanation of Benefits
EPO Epoetin Alfa
ERA Electronic Remittance Advice
ESRD End Stage Renal Disease
F&A Fraud and Abuse
FCA Full Claim Adjustment; or False Claim Act
FCN Financial Control Number
FDA Food and Drug Administration
FI Fiscal Intermediary
FO Field Office
FOI Freedom of Information
FOIA Freedom of Information Act
FR Federal Register
FTE Full Time Equivalency; or Full Time Employee
FY Fiscal Year
GAO General Accounting Office; or Government Accountability Office
GPCI Geographic Practice Cost Index
GPRO Group Reporting Option
HBP Hospital Based Physician
HCPCS Health Care Procedure Coding System (5-digit, alpha-numeric procedure code)
HHA Home Health Agency
HHS Health & Human Services (CMS is a branch of)
HI Hospital Insurance
HIC Health Insurance Claim (Number)
HIPAA Health Insurance Portability and Accountability Act
HME Home Medical Equipment
HMO Health Maintenance Organization
HO Hearing Officer
HPSA Health Professional Shortage Area
HRSA Health Resources Services Administration
ICD-9-CM Internal Classification of Diseases-9th Edition-Coding Manual (three-, four-, or five-digit codes based on specificity)
ICN Internal Control Number
ICU Intensive Care Unit
IDTF Independent Diagnostic Testing Facility
IIC Inflation Index Charge-Customary
IIP Inflation Index Charge-Prevailing
IL Independent Laboratory
IOM Internet-Only Manual
IP Independent Psychologist
IPL Independent Psychological Laboratory
IRP Incentive Rewards Program
IVR Integrated Voice Response System
JAC Jurisdictional Advisory Committee
LCER Limiting Charge Exception Report
LFS Laboratory Fee Schedule
LLP Limited License Practitioner
LMRP Local Medical Review Policy
LVP Licensed Vocational Nurse
MAC Medicare Administrative Contractor
MCS Multi Carrier System (processing system for Medicare Part B)
MD Medical Doctor
MDM Medical Decision Making
MEI Medicare Economic Index
MEDPARD Medicare Participating Physician/Supplier Directory
MIM Medicare Intermediary Manual (Part A)
MIP Medicare Integrity Program
MMA Medicare Modernization Act
MPFSDB Medicare Physician Fee Schedule Database
MR Medical Review
MR/UR Medical Review/Utilization Review
MSN Medicare Summary Notice
MSP Medicare Secondary Payer
MSO Management Service Organization
NA Non-assigned (claim)
NCCI National Correct Coding Initiative
NCD National Coverage Decision
NDAB National Diabetes Advisory Board
NDC National Drug Code
NETT National Emphysema Treatment Trials
NH Nursing Home
NMW Nurse Midwife
NOC Not Otherwise Classified Code (Anytime you use an NOC code on your Medicare claim, you must provide a detailed description of the service provided)
NON-PAR Non-Participating Provider
NOS Number of Service(s)
NP Nurse Practitioner
NPI National Provider Identifier
NPP Non-Physician Practitioner
NPRM Notices of Proposed Rule Making
NSC National Supplier Clearinghouse
NSF National Standard Format
OAS Office of Audit Services
OCFAA Office of Civil Fraud and Administration Adjudication
OCR Optical Claim Recognition
OD Doctor of Optometry
OI Office of Investigations
OIFO Office of Investigations Field Office
OIG Office of Inspector General
OMB Office of Management & Budget
O/P Overpayment
OPPS Outpatient Prospective Payment System
ORF Outpatient Rehabilitation Facilities
OSCAR Online Survey, Certification and Reporting (OSCAR System)
OT Occupational Therapist
OV Office Visit
PA Physician Assistant
PAR Participating (physician)
PAYER-ID Payer Identification (Number)
PC Professional Component
PCA Progressive Corrective Action
PDT Purchased Diagnostic Test
PECOS Provider Enrollment Chain and Ownership System
PHC Public Health Clinic
PHSA Public Health Service Act
PI Program Integrity
PIM Program Integrity Manual
PIMR Program Integrity Management Reporting System
PM Program Memorandum
POE AG Provider Outreach and Education Advisory Group
POS Place of Service or Point of Service Option (for an HMO)
PPO Preferred Provider Organization
PPR Physician Payment Reform
PPS Prospective Payment System
PPV Pneumococcal Pneumonia Vaccine
PQRI Physician Quality Reporting Initiative
PRN Provider Remittance Notice
PSC Program Safeguard Contractor
PT Physical Therapy; Physical Therapist; or Patient
PTAN Provider Transaction Access Number
QA Quality Assurance
QDC Quality Data Codes
QIO Quality Improvement Organization
RA Remittance Advice
RAC Recovery Audit Contractor
RBRVU Resource Based Relative Value Unit
RC Reasonable Charge
REP PAYEE Representative Payee
RHC Rural Health Clinic
RHHI Regional Home Health Intermediary
RN Registered Nurse
RO Regional Office (CMS)
ROS Review of Systems
RPT Registered Physical Therapist
RRB Railroad Retirement Board
RVU Relative Value Unit
RX Prescription
SDP Single Drug Pricer
SHIP Senior Health Insurance Program; or State Health Insurance Assistance Program
SMI Supplemental Medical Insurance
SNF Skilled Nursing Facility
SOS Site of Service
SP Specialty
SPR Standard Paper Remittance
SSA Social Security Administration
SSI Supplemental Security Income
SSN Social Security Number
TAN Treatment Authorization Number
TC Technical Component
TIN Taxpayer Identification Number
TMJ Temporomandibular Joint Dysfunction
TOS Type of Service
UR Utilization Review
USC United States Code
VA Veterans Administration
WC Worker’s Compensation
WPS Wisconsin Physicians Service
YTD Year-to-Date
ZPIC Zone Program Integrity Contractor
