| A | B |
|---|
| Medicare | federal insurance program for individuals age 65 years and older |
| end-stage renal disease (ESRD) | a group of permanent kidney disorders requiring dialysis or transplant |
| Federal Insurance Contribution Act (FICA) | provides for a federal system of old age, survivor, disability, and hospital insurance |
| Medicare Part A | hospital insurance |
| Medicare Part B | physicians' care (original, or traditional, Medicare) |
| Medicare Part C | Medicare Advantage - managed care |
| Medicare Part D | prescription drug program |
| non-covered services | services that are not paid by Medicare |
| beneficiary | individual who has health insurance through Medicare or Medicaid |
| Medicare Administrative Contractors (MACs) | Medicare Carriers and Fiscal Intermediaries |
| allowable charges | fees Medicare permits for a particular service or supply |
| dual eligibles | individuals who qualify for both Medicare and Medicaid |
| Medicare supplement policy | Medigap - pays for Medicare deductibles and coinsurance |
| open enrollment period | period of time where individual can enroll in Medicare Part B |
| Medicare Secondary Payer | Medicare is not responsible for paying services first |
| self-referring | member goes outside the network |
| lifetime (one-time) release of information form | signed only once eliminating annual updates |
| advanced beneficiary notice (ABN) | informs the patient in advance that Medicare will deny payment of procedure or treatment |
| local coverage determination (LCD) | information pertaining to when a procedure is considered medically reasonable and necessary |
| health insurance claim number (HICN) | format of nine numerical characters, followed by one alpha chatacter |
| resource-based relative value scale (RBRVS) | method which Medicare bases its payments for physicians' services |
| relative value scale | method of determining reimbursement for medical services on the basis of a standard unit value |
| limiting charge | highest amount of money a Medicare beneficiary can be charged for a covered service |
| initial claims | claims that are submitted for the first time |
| claim adjustment reason code | explanation why the claim or service line was paid differently from how it was billed |
| Medicare Summary Notice | document received by the beneficiary to describe how payment was made to provider |
| downcoding | reporting lower-level evaluation and management codes on claims that result in billing Medicare a lesser fee |
| Recovery Audit Contractor (RAC) | detect and correct past improper payments |
| Quality Improvement Organizations (QIOs) | private organizations that are trained to review medical care, help with beneficiary complaints, and to make improvements |
| Beneficiary Complaint Response Program | handles complaints by Medicare beneficiaries either written or phoned |
