Glossary of Terms Used in Medicare
Original Article

Aberrancy - Medical services that deviate from what is considered normal or typical when compared to the national average.

Abuse - Any incident or practice of a provider, physician, supplier, or beneficiary which, although not usually considered fraudulent, is inconsistent with accepted and sound medical, business, or fiscal practices and directly or indirectly results in unnecessary costs to the Medicare program, improper reimbursement, or program reimbursement for services that fail to meet professionally recognized standards of care which are medically necessary.

Adjudication - The process of deciding whether to pay, pend, or reject a claim based upon the information submitted, the eligibility of the recipients, and the available benefits.

Adjustment - Additional payment or correction of records on a previously processed claim.

Administrative Law Judge (ALJ) - Hearing official assigned to the Office of Hearings and Appeals. Conducts evidentiary hearings on appeals from Medicare Part A and B determinations.

Admission - Entry to a hospital or other health care institution as a patient.

Advanced Beneficiary Notice (ABN) - When the provider believes that Medicare will deny payment for a service as "not reasonable and necessary," an advance written notice to the beneficiary can protect the provider from liability.

ALJ Hearing - The ALJ hearing is a quasi-judicial administrative hearing conducted by a Federal ALJ. It results in a new decision by an independent reviewer.

Allowed Amount - The amount Medicare determines to be the maximum amount allowable for any given service. There is a 5% differential between the approved charges for services rendered by participating providers and the approved charges for services rendered by nonparticipating providers. The participating approved amount is 5% higher.

Ambulatory Surgical Center (ASC) - A free standing facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.

American Medical Association (AMA) - The national voluntary nonprofit organization of professional medical personnel, composed of state and territorial medical societies and component county medical societies. The AMA attempts to speak for physicians nationally, conducts educational and publication services to members, and (with member's dues) sponsors research to improve medical knowledge. The AMA advocates for the medical profession and for public health.

American National Standards Institute (ANSI) - A national voluntary organization of firms and private individuals who develop industry standards used in a wide variety of business applications.

Amount in Controversy - The difference between the amount charged the beneficiary less the amount the Medicare carrier allowed, less any remaining Part B Cash Deductible and/or, if applicable, Part B Blood Deductible, less 20 percent of the remainder. To meet the amount in controversy requirement, a beneficiary or provider may combine any series of claims for Part B services as long as the appeal is timely filed for all claims at issue and the claims are properly at the level of the appeal requested.

Ancillary Services - Services available to a beneficiary other than room, board and surgery, e.g., laboratory, x-ray, drugs, etc.

ANSI ASC X12 837 - Industry standard for a healthcare claim (one of two formats accepted for Medicare).

ANSI ASC Z12 835 - Industry standard for electronic remittance advice.

Appeal - Written or verbal statement from a customer that conveys an explicit or implicit request for review of the initial determination of a claim, or a dissatisfaction with the most recent determination.

Assignment - An arrangement whereby a provider of service or supplier agrees to accept the Medicare approved amount as full payment for services and supplies covered under Medicare Part B. Medicare usually pays 80% of the approved amount directly to the provider of service or supplier after the beneficiary meets the annual Part B deductible of $100. The beneficiary pays the other 20%.

Assistant-at-surgery - A surgeon who gives aid to and supports a primary surgeon during a surgical procedure.

Attending Physician - The physician rendering the major portion of care or having primary responsibility for the care of the patient's major condition or diagnosis.

Automated Response Unit (ARU) - The computerized telephone answering service allowing a beneficiary or provider to check claim status using a touch tone telephone.

Balance Billing - The difference between the billed amount and the amount approved by Medicare.

Beneficiary - Term used to identify any individual eligible for Medicare benefits.

Benefit Period - A benefit period is a way of measuring a beneficiary's use of hospital and skilled nursing facility services covered by Medicare. A benefit period begins the day the beneficiary is hospitalized. It ends after the beneficiary has been out of the hospital or other facility that primarily provides skilled nursing or rehabilitation services for 60 days in a row. If the beneficiary is hospitalized after 60 days, a new benefit period begins, most Part A benefits are renewed, and the beneficiary must pay a new inpatient hospital deductible. Benefit periods are unlimited.

Bilateral Surgery - Procedures that are performed on both sides of the body, or organ site of a paired physiological pain, during the same operative session or on the same day.

Billed Amount - The amount charged for each service performed by the provider.

CABBS - Carrier Bulletin Board System. CABBS is the primary platform for asynchronous telecommunications between submitters and the NHIC processing system, with file upload and download capabilities. A bulletin board (or BBS) system is a computer equipped to automatically answer incoming calls and allow users to leave messages and access information.

Calendar Year - January 1 through December 31.

Correct Coding Initiative (CCI) - The national "rebundling" initiative that ensures comprehensive and component, and mutually exclusive procedures are not separately paid.

Carrier - Private organizations, usually insurance companies, contracting with HCFA to process claims under Part B of Medicare.

Carrier Advisory Committee (CAC) - A formal mechanism for: a) providers in a state to be informed of, and participate in, the development of medical policy in an advisory capacity; b) to discuss and improve administrative policies that are discretionary, and; c) for information exchange between the Medicare carrier, health care professionals and Medicare beneficiaries.

CHAMPUS - Civilian Health and Medical Program of the Uniformed Services. A federal government program embracing dependents of active duty or retired status of the Armed Forces.

Claim - A written request for payment of physician services, other medical services and supplies provided to Medicare beneficiaries.

Clearinghouse - An entity that accepts paper or electronic transactions from another organization, performs high level edits and value-added processing, then electronically routes the information to a receiving entity. Clearinghouses also perform data translations from one format to another.

Clinical Laboratory Improvement Amendment (CLIA) - An amendment which states that all clinical laboratory services rendered to Medicare beneficiaries must be performed by a provider who has certification from the CLIA program.

COBRA - Consolidated Omnibus Budget Reconciliation Act.

Coinsurance - The portion or percentage of each Medicare approved amount a Medicare beneficiary must pay after they have paid the deductible.

Common Working File (CWF) - A query/reply system which determines a beneficiary's deductible and entitlement status.

Comprehensive Medical Review (CMR) - A thorough analysis of a sample of processed claims and all pertinent data (such as medical records, beneficiary payment history, etc.), for selected providers, for a specified time period.

Comparative Performance Report (CPR) - A report to monitor and profile physician's billing patterns within each area or locality and provide comparative data to physicians whose utilization patterns vary significantly from other physicians in the same payment and/or locality.

Conditional Payment - Medicare makes payment on third party liability cases so providers and beneficiaries do not have to wait for the case to be settled in the courts for payment. Once the case is settled, Medicare receives reimbursement by the other insurance company.

Coordination of Benefits (COB) - The determination of primary, secondary, and tertiary insurer responsibility for a patient's health claim and the passing of claim and payment information between insurers.

Coordination Period - Specified period of time when the employer plan is the primary payer to Medicare.

Correspondence Control Number (CCN) - Number assigned to an inquiry or appeal (written or telephone), which is used for identification purposes.

Co-surgery - A single surgical procedure which requires the skills of two surgeons of different specialties.

Covered Services - Services rendered to Medicare patients that are reimbursable by the program to the provider of service or supplier.

CPT - Physicians' Current Procedural Terminology (in other words, procedure codes, used along with HCPCS codes).

Cycle Time - Time required to pay a claim or respond to "inquiries."

Date of Service - The date the services were actually performed.

Deductible - The amount a beneficiary pays for Medicare approved expenses before Medicare starts to pay.

Denial - Determination that certain care or services cannot be reimbursed.

DHHS - Department of Health and Human Services.

Diagnosis - Identifies the condition, cause or disease of the patient (see also "ICD-9-CM").

Diagnostic - Procedure used to discover the nature and underlying cause of the illness.

Durable Medical Equipment Regional Carrier (DMERC) - The Medicare carriers that process claims for durable medical equipment, prosthetics, orthotics, and supplies. CIGNA is the DMERC for the California NHIC region. United Healthcare ^TM is the DMERC for Maine, Massachusetts, New Hampshire, and Vermont NHIC region.

EDI - Electronic Data Interchange. A computer to computer exchange of business information in a standard format.

Electronic Funds Transfer (EFT) - Movement of funds from one bank account to another using communications networks to activate banking transactions.

Electronic Remittance Advice (ERA) - A provider who submits claims electronically can choose to receive their Medicare Remittances electronically. ERA allows providers to systemically maintain accounts receivable when used with appropriate accounting software.

Eligible - One who is qualified to receive benefits.

Eligibility Date - Date from which benefits are available.

Employer Group Health Plan (EGHP) - Group health plan provided by a single employer of 20 or more employees or provided by an employee organization associated with that employer.

End Stage Renal Disease (ESRD) - A person will be classified as having ESRD when there is permanent kidney failure, and dialysis or kidney transplant are the only two options for treatment.

Enrollment - The means by which one establishes membership.

Entitlement - The first date that a Medicare beneficiary can receive benefits under the Medicare program (the date of entitlement begins at age 65 for most beneficiaries).

ESRD - End Stage Renal Disease

Experimental and Investigational - Any treatment, procedure, facility, equipment, drugs, drug usage, devices or suppliers not generally recognized as accepted medical practice. Includes such services or supplies requiring federal or other governmental agency approval not granted at the time services were rendered.

Explanation of Benefits (EOB) - The explanation generated by an insurance that pays BEFORE Medicare pays, i.e., Employer Group Health Plan, workers compensation, etc.

Explanation of Medicare Benefits (EOMB) - The written correspondence that is sent to a beneficiary verifying services and supplies provided by a provider and indicating coverage decisions.

Fair Hearing - See "Hearing."

FDA - Food and Drug Administration

Federal Employee Program (FEP) - Medical program designed for federal employees and their families.

Fee-for-Service - A financing system for health care service in which a specified fee is payable for each individual service.

Fee Schedule - A list of certain services and payable amounts indicating the maximum Medicare payment for the service. Method of payment is calculated by the Resource Base Relative Value Unit Scale by which Medicare reimburses physician and nonphysician services. Fee schedules are sent to providers in the fall.

Fiscal Year - October 1 through September 30.

Focused Medical Review (FMR) - A program in which Medicare carriers provide a more targeted medical review of those items, services, and providers that present the greatest risk of inappropriate Medicare Part B program payment.

Fraud - Intentional deception or misrepresentation which an individual or entity makes, knowing it to be false and that the deception could or does result in some unauthorized benefit.

Freedom of Information Act (FOIA) - Enacted in 1966 in order to establish the presumption that records in the possession of agencies and departments of the Executive Branch of the United States Government are accessible to the people; set standards for determining which records must be disclosed and which records can be withheld.

Global Fee - Combined technical (equipment charges) and professional (physician charge) billings or payment.

Global Surgery - A standard package of preoperative, intraoperative, and postoperative services included in the payment for a surgical procedure.

Group Provider Identification Number - A provider identification number assigned to an entity where more than one practitioner is rendering services. This number allows payment to be made under one name and one tax identification number.

HCFA-855 - This General Application is for providers / suppliers who are not currently enrolled to bill the Medicare program (pastel blue form). Applicants who are adding a new practice location, as opposed to relocating an existing practice location, must complete the HCFA-855.

HCFA-855C - Any enrolled provider/supplier who needs to report certain changes can use the 855C to update his/her file. This includes providers/suppliers who were enrolled prior to May 1996 and did not use the HCFA-855 General Enrollment form to enroll in Medicare.

HCFA-855G - This form is for applicants who render services and submit billings under group practice settings. An applicant must complete an 855G for each practice that he/she is a member of (pastel yellow form). The applicant must also enroll individually by completing the 855 General Application. Providers/suppliers who are already enrolled can change a group member by completing HCFA-855G.

HCFA-855S - The form for Durable Medical Equipment Prosthetic Orthotic Suppliers (DMEPOS). Only available from the DMERC.

HCFA-1491 - Claim form specific to ambulance claims (ambulance providers may bill electronically, or use this form or the HCFA-1500 claim form).

HCFA-1500 - Multi-purpose claim form prescribed by HCFA for the Medicare program for claims from providers of service and suppliers.

HCPCS - Health Care Financing Administration Common Procedure Coding System. HCPCS includes three levels of procedure codes as well as modifiers. Level I contains the AMA's CPT-4 codes. Level II contains alpha-numeric codes maintained by HCFA. Level III contains carrier-assigned local codes.

Health Care Financing Administration (HCFA) - The division of the Department of Health and Human Services responsible for administering the Medicare program.

Health Insurance Claim Number (HIC) - Identification number assigned to Medicare beneficiaries by the Social Security Administration; usually consists of the individual's Social Security number, preceded by an alpha prefix.

Health Maintenance Organization (HMO) - A public or private organization providing, either directly or through arrangements with others, a comprehensive range of health services to enrolled members who live within a specified service area. Payment is based on a predetermined periodic rate, or periodic per capita rate, without regard to the frequency or extent of covered services furnished to any particular member. The HMO must also meet statutory requirements.

Health Professional Shortage Area (HPSA) - An area defined by the Department of Health and Human Services, Public Health Service Division of Shortage Designation, as having a shortage of health professionals. A HPSA can be urban or rural.

Hearing - This is the second level in the administrative appeals process which generally follows a review determination. A hearing is held by a Hearing Officer to determine if the carrier's action on a claim complied with Medicare law. A hearing may not be held unless the amount in controversy (minus deductible and coinsurance) is at least $100. More than one claim may be used to satisfy the $100 requirement; however, a hearing must be requested within six months of the first review.

Home Health Agency - An approved association or organization where a Medicare patient receives skilled nursing and/or therapeutic care in the home.

Hospice Care - Care provided for beneficiaries who have a terminal illness with a life expectancy of six months or less; these beneficiaries have the option of electing hospice coverage instead of the standard Medicare coverage.

Hospital - Institution with organized medical staff, with permanent facilities that include inpatient beds; and with medical services, including physician services and continuous nursing services, to provide diagnosis and treatment for patients who have a variety of medical conditions, both surgical and nonsurgical.

ICD-9-CM - International Classification of Diseases Clinical Modification (in other words, diagnosis codes).

Intelligent Character Recognition (ICR) - A system used to capture claim information directly from the HCFA-1500 claim form; all information which is captured by the computer is transferred into an electronic file which is then passed to the Medicare claims processing system.

Incident to Physician Services - Services that are provided as an integral part of the physician services, may be provided by auxiliary personnel.

Inquiry - All claimant oral and written contacts which do not request a reexamination of or state a dissatisfaction with the previous determination (in other words, an appeal). Usually pertains to claim status or general information such as deductible, entitlement, etc.

Internal Control Number (ICN) - A 13-digit number assigned to a claim, which is used for identification purposes and retrieval purposes, if necessary.

Julian Date - A three-digit number indicating the day of the year. January 1 is 001 and December 31 is 365 or 366.

Large Group Health Plan (LGHP) - A plan provided by an employer who employs 100 or more persons or a plan belonging to a multi-employer plan where at least one employer has 100 or more full or part time employees.

Limitation of Liability - A provision designed to protect the beneficiary from liability under certain conditions when services he/she received are found not to be reasonable and necessary.

Limiting Charge - Congress-enacted law which limits what a physician may charge Medicare beneficiaries for medical services; every charge on a NONASSIGNED Medicare claim for physician's services is subject to a legal limit called the limiting charge; these physician charges to a Medicare beneficiary may not exceed the maximum of 115% of the Medicare allowed amount for any service or procedure rendered.

Limiting Charge Exception Report (LCER) - A report which is sent to providers whom the Medicare carrier has identified as exceeding their limiting charge; designed for informational purposes only.

Limiting Charge Monitoring Report (LCMR) - A retrospective review and notice sent to those providers who fail to meet acceptable levels of limiting charge compliance; these noncompliance notices are mailed after completion of a monthly review of the Limiting Charge Exception Report files.

Locality - Geographic areas defined by Medicare for determining payment amounts.

MCM - Medicare Carriers Manual.

Medicaid (Medi-Cal in California) - A medical coverage program jointly funded by both the states and the federal governments; for those residents who qualify because of an annual income which falls below the state or nationally indicated poverty level.

Medical Review - The review of medical records or information as it relates to services rendered and billed by a provider or beneficiary for payment. This review is performed by the medical staff of physicians, registered nurses, licensed practical nurses, etc.

Medically Necessary - The level of services and supplies (frequency, extent and type) that is adequate for the diagnosis and treatment of illness or injury. Medical necessity includes the concept of appropriate medical care.

Medicare - A Federal health insurance program which provides coverage for people 65 and older, for certain disabled people, and for some people with End Stage Renal Disease (ESRD); enacted into law in 1965 by Congress through Title XVIII of the Federal Social Security Act, and managed by the Health Care Financing Administration (HCFA), a branch of the Department of Health and Human Services (DHHS).

Medicare Entitlement - When an individual becomes entitled to Medicare, he/she receives a Health Insurance Claim card which shows his/her name, sex, Medicare number, and the effective dates of entitlement to hospital (Part A) benefits and medical (Part B) benefits. Entitlement begins the first day of the month of the individual's birth and ends the last day of the month, with the exception of death.

Medicare Remittance Notice (MRN) - A summarized statement for providers including payment information for one or more beneficiaries.

Medicare Secondary Payer (MSP) - There is another insurance company that is primary to Medicare; the primary insurance company pays first and Medicare would be secondary payer for the service(s).

Medigap - A Medicare supplemental insurance policy or other health benefit plan offered by a private company to those entitled to Medicare benefits. These plans provide reimbursement for Medicare approved charges not reimbursable because of the applicability of deductible, co-insurance amounts or other Medicare imposed limitations.

Modifiers - Two digit codes that indicate services or procedures have been altered by some specific circumstance. Modifiers do not change the definition of the reported procedure codes.

NHIC - National Heritage Insurance Company, the Medicare Part B Carrier (except for Durable Medical Equipment) for both Northern California and San Bernardino and Riverside Counties and the states of Maine, Massachusetts, New Hampshire, and Vermont.

National Provider Identifier (NPI) - A unique standardized identifier for a providers and suppliers of health care services, as required under the Administrative Simplification are of the Health Insurance Portability and Accountability Act (HIPAA). The NPI consists of an eight digit alphanumeric identifier plus a two digit alphanumeric location identifier to indicate the provider's practice location. NPIs are good for life and only the location identifier may change. NPI has not yet been implemented.

Nonassigned Claim - A claim potentially payable directly to the Medicare beneficiary.

Noncovered Services - Services which Medicare does not pay for, but the patient does. For instance, Medicare does not pay for most self-administered prescription drugs or immunization (except for pneumococcal, influenza, hepatitis B vaccinations, or immunizations required because of an injury or immediate risk of infections). Other examples of service not covered by Medicare are: routine physical examinations, routine health screenings, such as serum cholesterol screening, hearing test, diabetes screening, thyroid function screening, etc.

Nonparticipating Provider - Physicians/suppliers who do not sign an agreement to accept assignment on all Medicare claims. They may accept assignment on a claim-by-claim basis and may bill the patient up to the limiting charge amount for nonassigned claims.

Nonphysician Practitioner - A health care provider who meets state licensing requirements to provide specific medical services. Medicare payment may be made for the professional services of many nonphysician practitioners, such as certified registered nurse anesthetists/anesthesia assistants, physician assistants, clinical nurse specialists, nurse practitioners, nurse midwives, physical therapists, occupational therapists, clinical psychologists, licensed clinical social workers, and audiologists.

National Standard Format (NSF) - Also known as "flat file" format, it is one of two standardizes electronic formats currently accepted by Medicare.

Office of the Inspector General (OIG) - Government office that is responsible for monitoring and investigating abuse and fraud.

Omnibus Budget Reconciliation Act of 1990 (OBRA) - A legislative act passed by Congress which provides for replacing the current reasonable charge mechanism of actual, customary, and prevailing charges with a Resource Based Relative Value Scale fee schedule beginning in 1992, with the transition period lasting until 1996.

Ordering Physician - The physician that orders a service or diagnostic test.

Part A (Hospital Insurance) - Coverage which helps pay for inpatient hospital care, some inpatient care in a skilled nursing facility, some home healthcare, and hospice care. Hospitals submit their claims to their Part A intermediaries; usually premium free with a deductible per benefit period.

Part B (Medical Insurance) - Coverage which helps pay for medical and surgical services by physicians, providers of service, and suppliers, as well as certain other health benefits such as ambulance transportation, durable medical equipment, outpatient hospital services, and independent laboratory services; designated to complement the coverage provided by Part A of the program; beneficiaries pay a premium and are responsible for an annual deductible.

Participating - An eligible provider or supplier who has entered into an agreement to accept assignment for all services rendered to Medicare patients, and to accept the Medicare approved amount as payment in full for all services rendered. A participating provider or supplier may not ordinarily collect from the beneficiary more than the applicable deductible and coinsurance for covered services. There are significant benefits to become participating such as: higher allowances, toll-free telephone access for electronically submitting claims, no legal charge limits, Medigap transfers and listing in the Participating Physicians/Suppliers Directory.

Patient Eligibility - Requirements entitling individuals to Medicare benefits.

Patient - A person under treatment or care, as by a physician or surgeon, or in a facility.

Payers - People or businesses that have purchased coverage and/or paid for health care services (government, employers, and insurers).

PAYERID - A nationally standardized unique identifier for all payers of health care benefits, as required under the Administrative Simplification area of the Health Insurance Portability and Accountability Act (HIPAA). The PAYERID will facilitate Cordination of Benefits processing. The proposed PAYERID is nine-digits long. PAYERID has not yet been implemented.

Payment Floor - The timeframe established for carrier payment of Medicare Part B claims. Electronically submitted claims are paid a minimum of 13 days after the date of receipt, while paper claims will be paid a minimum of 27 days after the date of receipt. All clean claims (claims which do not require additional development or other documentation for processing), whether electronic or paper, must be processed within 30 days of receipt or the carrier will be required to pay interest in addition to allowances for covered services.

Payment Safeguard Unit (PSU)/ Fraud and Abuse Investigation Unit - A unit that controls and develops potential Medicare fraud and abuse cases.

Physician Payment Reform (PPR) - Provision enacted with the passing of the Omnibus Budget Reconciliation Act of 1989, where Congress provided for major changes in the manner which payment for services of physicians was determined under Medicare.

Place of Service - Where a service was performed, for example, inpatient hospital, outpatient hospital, doctor's office, etc.

Practitioner - An individual who provides health care services; physicians and non-physicians. This not does include service companies.

Premium - The amount paid by a Medicare beneficiary to obtain Part B (medical) insurance, or in some cases Part A (hospital) insurance.

Primary Payer - Insurance which pays first.

Privacy Act of 1974 - Act which regulates federal government agency record keeping and disclosure practices, allowing most individuals to seek access to federal agency records about themselves, and requiring that the personal information in agency files be accurate, complete, relevant, and timely.

Procedure Code - A HCPCS code used by a physician or provider of services to describe the procedure or service rendered to the patient.

Professional Component (PC) - The physician work portion of diagnostic tests (e.g. interpretation).

Prolonged Physician Services - Physician services involving direct (face-to-face) patient contact beyond that of the usual service.

Provider - A generic term for any person or entity approved to give care to Medicare beneficiaries and to receive payment from Medicare.

Provider Identification Number (PIN) - An identification number assigned to providers by the carrier; required for any provider, regardless of participation status, who wishes to submit claims to Medicare for reimbursement.

Purchased Diagnostic Tests - A test (such as an ECG, x-ray, ultrasound, etc.) purchased from an outside supplier for which a physician bills, but does not personally perform or supervise.

Rebundling - A comprehensive standardized package of computerized edits to identify and prevent improper reporting on a national level.

Referring Physician - The physician who refers a patient for a service or supply.

Rejected/Returned Claim - Process where a claim is returned/rejected because essential information (e.g., ICD-9-CM Code or Unique Physician Identification Number (UPIN)) is missing. This action is not appealable. The claimant must resubmit the claim and may not bill the beneficiary until Medicare gives the claimant a decision.

Reopening - A re-evaluation of a claim or review determination. It is not an appeal right. It is a discretionary action in response to the identification of an error, fraud or the submission of new material and information not available at the time of the last adjudication.

Resource Based Relative Value Scale (RBRVS) - A scale which assigns values to procedures in relation to one another; used to establish the Medicare Fee Schedule.

Review - The first formal level of appeal following the initial processing of a Part B claim. It is a second look at the claim and supporting documentation by a different employee.

Revised Determination or Decision - A revised determination or decision is one in which: The end result is changed (for example, a service previously found to be not covered is now found to be covered or the reasonable charge allowed for the service is determined to be incorrect); or
The end result is not changed, but a party might be disadvantaged by the revision (for example, a request for payment on an assigned claim previously disallowed because the services were not medically necessary and therefore subject to the waiver of liability provisions, is now to be disallowed on a basis that precludes consideration of waiver of liability).

Roster Billing - Simplified billing process used when a provider accepts assignment and bills for mass immunizations.

Site of Service Differential - Payment for some services that are routinely furnished in physicians' offices are reduced when such services are furnished in the following hospital settings: Outpatient Hospital; Emergency Room-Hospital; Comprehensive Outpatient Rehabilitation Facility; ESRD Treatment Facility; and effective for 1994 dates of service, the following settings: Inpatient Hospital; Inpatient Psychiatric Facility; and Comprehensive Inpatient Rehabilitation Facility.

Social Security Administration (SSA) - The branch of the Department of Health and Human Services operating the various programs funded under the Social Security Act. It also determines beneficiary eligibilty for Medicare benefits.

Surrogate UPIN - A temporary UPIN that a provider may use until one is assigned.

Team Surgery - A single surgical procedure which requires the skills of more than two surgeons of different specialties, working together to carry out various portions of a complicated surgical procedure.

Technical Component (TC) - The performance of a diagnostic test, that is, staff and equipment costs.

TEFRA - Tax Equity and Fiscal Responsibility Act of 1982.

Telephone Device for the Deaf (TDD) - A special piece of equipment used by an individual with a hearing impairment to improve hearing capabilities and therefore communications with others.

Third Party Liability (TPL) - When a Beneficiary sues another party due to an accident, such as a fall on someone's property.

Time Limit - The specified period of time during which a notice of claim or appeal must be filed.

Title XVIII - The title of the Social Security Act which contains the principal legislative authority for the Medicare program, and therefore, a common name for the program.

Unfavorable Determination - A determination or decision is "unfavorable" if, for initial decisions, it is a complete denial of coverage/payment, or, for subsequent appeals, it fails to advance the interests of the claimant.

Unique Provider Identification Number (UPIN) - A six character identifier (one alpha, five numeric) assigned to physicians by the Health Care Financing Administration.

Unprocessable Claim - Process where a claim is returned/rejected because essential information such as the ICD-9-CM Code or Unique Physician Identification Number (UPIN) is missing. This action is not appealable. The claimant must resubmit the claim and may not bill the beneficiary until Medicare gives the claimant a decision.

Waiver of Liability Provision - A provision which states that if the provider informed the beneficiary in writing before the item or service was furnished that Medicare is likely to deny payment for the item or service rendered as "not reasonable and necessary," and obtained his or her agreement to pay, the provider's liability is waived and payment is made to the provider by the benficiary.

Working Aged - Employed individuals aged 65 or over and individuals aged 65 or over with employed spouses of any age.