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    Medical Assistance Programs Dictionary

    Use this page to find definitions/descriptions of acronyms, words, and terms that are frequently used within the Office of Medical Assistance Programs.

    AAAArea Agency on Aging - The single local agency designated by the Pennsylvania Department of Aging within each planning and service area to administer the delivery of a comprehensive and coordinated plan of social and other services and activities.
    ACCESS CardMedical Assistance Identification Card - The Pennsylvania ACCESS card is issued to individuals for Medical Assistance benefits. The card is one of the methods that may be used by Medical Assistance providers to verify an MA consumer’s eligibility for medical services through the Eligibility Verification System (see EVS).
    ADAAmericans with Disabilities Act
    ADAPAIDS Drug Assistance Program (see SBPB)
    AIDSAcquired Immunodeficiency Syndrome
    Alert(Remittance Advice Alert) – a special notice that is sent to Medical Assistance providers with their remittance advices to relay various information to them (important messages, reminders about billing procedures, etc.)
    Alternate Payment NameThe name of the individual that the eligible Medical Assistance consumer has appointed to transact their benefits.
    APDAdvance Planning Document
    AURAutomated Utilization Review
    BDCMBureau of Data and Claims Management
    Benefit ConsultantAn individual or group that assists Medical Assistance recipients with choosing a physical health managed care plan, selecting a primary care provider, and obtaining information on behavioral health services.
    BFFSPBureau of Fee for Service Programs
    BHBehavioral Health (services) – Commonly known as mental health and/or drug and alcohol services.
    BH-MCOBehavioral Health Managed Care Organization – An entity directly operated by the county government or licensed by the Commonwealth as a Health Maintenance Organization or risk-assuming Preferred Provider Organization which manages the purchase and provision of behavioral health services.
    BMCOBureau of Managed Care Operations
    BPBPBureau of Policy, Budget and Planning
    BPIBureau of Program Integrity
    Bulletin(Medical Assistance Bulletin) – a formal mailing to Medical Assistance providers to relay various information to them (change in MA policy, change in billing procedures, fee schedule changes, etc.) Bulletin Search
    CAOCounty Assistance Offices -- CAOs administers all the benefit programs, including Medical Assistance, at the local level. Department staff in these offices perform necessary functions such as determining and maintaining Medical Assistance recipient eligibility.
    CapitationA fee the Department of Public Welfare pays periodically to a contractor for each Medical Assistance recipient enrolled under a contract for the provision of medical services, whether or not the Medical Assistance recipient receives services during the period covered by the fee.
    CARCClaim Adjustment Reason Code
    CDCCenters for Disease Control and Prevention
    CFOChief Financial Officer
    CFRCode of Federal Regulations
    CHIPChildren's Health Insurance Program
    Children in Substitute CareChildren who have been adjudicated dependent or delinquent and are in the legal custody of a public agency and/or under the jurisdiction of the juvenile court, and are living outside of their homes in any of the following settings: shelter homes, foster homes, group homes, supervised independent living, residential treatment facilities, and residential child care facilities.
    CHRConcurrent Hospital Review
    CISClient Information System – the Department’s automated file that contains demographic and eligibility information for all Medical Assistance recipients.
    CMICase Mix Index - a number value score that describes the relative resource use for the average resident in each of the groups under the RUG-III classification system based on the assessed needs of the resident
    CMICCentral Management Information Center
    CMSCenters for Medicare and Medicaid Services
    COBCoordination of Benefits
    COBRACongressional (or Consolidated) Omnibus Budget Reconciliation Act
    COLACost of Living Adjustment
    ContractorThe successful bidder or its successor approved by the Department.
    CPT(Physician’s) Current Procedure Terminology
    CRFCommunity Residential Facility
    CRNClaim Reference Number – a 10-digit identification number assigned to every Medical Assistance claim or claim adjustment received by the Department for tracking purposes
    CRNPCertified Registered Nurse Practitioner
    CSPCommunity Support Program
    DAPDisability Advocacy Program
    DEADrug Enforcement Agency
    Developmental DisabilityMental retardation is the most prevalent of a broad spectrum of developmental disabilities. The term "developmental disability" means a severe, chronic disability of an individual that is:
    * attributable to a mental or physical impairment or combination of mental or physical impairments;
    * manifested before the individual attains age 22;
    * likely to continue indefinitely;
    * results in substantial functional limitations in three of more the following areas of life activity: self care; receptive and expressive language; learning; mobility; capacity for independent living; and economic self sufficiency.
    * reflects the individual’s need for a combination and sequence of special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in developmental disabilities if services are not provided.
    DHHSU.S. Department of Health and Human Services
    DisabledAny person who has a physical or mental impairment that substantially limits one or more life activities (e.g. caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, learning, and working); or has a record of an impairment (has a history of, or has been misclassified as, having a mental or physical impairment) that substantially limits one or more major life activities; or is regarded as having an impairment.
    DMEDurable Medical Equipment
    DOHDepartment of Health
    DOIDepartment of Insurance
    DPWDepartment of Public Welfare
    DRGDiagnostic Related Group
    DRODomestic Relations Office
    DSHDisproportionate Share
    Dual EligibleAn individual who is eligible to receive services through both Medicare and Medicaid (Medical Assistance)
    DURDrug Utilization Review
    EBTElectronic Benefits Transfer
    ECMElectronic Claims Management
    EDIElectronic Data Interchange
    EDSElectronic Data Systems, Inc. – the claims processing contractor for the Pennsylvania Medical Assistance Program
    EFTElectronic Funds Transfer
    EINEmployer Identification Number
    EMCElectronic Media Claims
    EMSEmergency Medical Services
    EOMBExplanation of Medical Benefits
    EPSDTEarly and Periodic Screening, Diagnosis and Treatment
    EREmergency Room
    EVSEligibility Verification System
    Facility MA CMIFacility Medical Assistance Case Mix Index - the arithmetic mean CMI for MA residents in the nursing facility for whom the Department paid an MA day of care on the picture date.
    Family Planning ServicesContraceptive needs met through the provision of educational, medical, and social services. Services enable individuals voluntarily to determine family size, to space children, and to prevent or reduce the incidence of unplanned pregnancies. Services are made available without regard to marital status, age, sex, or parenthood.
    FDAFood and Drug Administration
    FFSFee-for-Service – payment on a per-service basis for health care services provided to Medical Assistance recipients
    FQHCFederally Qualified Health Center
    FYFiscal Year
    GAGross Adjustment or General Assistance (depends on context used)
    Gross Adjustment –
    General Assistance - Assistance for persons not eligible for a Federal Category; usually adults without children that have a permanent or temporary disability that precludes employment. Must meet income and assets limits.
    HBPHealthy Beginnings Plus
    HC-L/CHealthChoices Lehigh/Capital – The mandatory Medical Assistance managed care program for the counties of Adams, Berks, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and York.
    HCPCSHCFA Common Procedure Coding System
    HC-SEHealthChoices Southeast – The mandatory Medical Assistance managed care program in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.
    HC-SWHealthChoices Southwest – The mandatory Medical Assistance managed care program for Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland counties.
    HealthChoicesThe name of Pennsylvania’s 1915(b) waiver program to provide mandatory managed health care to Medical Assistance recipients.
    HIPAAHealth Insurance Portability and Accountability Act
    HEDISHealthplan Employer Data Information Set
    HIPPHealth Insurance Premium Payback
    HIVHuman Immunodeficiency Virus
    HMOHealth Maintenance Organization – A public or private organization organized under state law that is a federally-qualified health maintenance organization or meets the State Plan’s definition of a health maintenance organization.
    ICFIntermediate Care Facility
    ICF/MRIntermediate Care Facility for the Mentally Retarded
    IEAPIndependent Enrollment and Assistance Program
    IEVSIncome Eligibility Verification System
    IFBInvitation for Bid
    IGTIntergovernmental Transfer Agreement - the formal document that executes the transfer of funds or certification of funds to the Commonwealth by another unit of government within the Commonwealth in accordance with Section 1903 of the Social Security Act (42 U.S.C.A. subsection 1396b(w)(6)(A).
    IRSInternal Revenue Service
    ITInformation Technology
    ITBInvitation to Bid
    JCAHOJoint Commission for the Accreditation of Healthcare Organizations
    JDCJuvenile Detention Center
    LANLocal Area Network
    LIHEAPLow Income Home Energy Assistance Program
    LTLLong Term Living
    LTCMSLong Term Care Management System
    MAMedical Assistance
    MAACMedical Assistance Advisory Committee
    MACMaximum Allowed Cost
    MAID (number)Medical Assistance Identification Number
    MAMISMedical Assistance Management Information System
    MANMetropolitan Area Network
    MCOManaged Care Organization – An entity which manages the purchase and provision of physical or behavioral health services for eligible Medical Assistance recipients.
    MDSMinimum Data Set - one of the three components of the federally designed Resident Assessment Instrument (RAI). The RAI includes the MDS, the Resident Assessment Protocols and Utilization Guidelines. The MDS is a minimum care of assessment items with definitions and coding categories needed to comprehensively assess a nursing facility resident.
    MEDAMedical Eligibility Determination Automation
    MFCUMedicaid Fraud Control Unit
    MH/MRMental Health/Mental Retardation
    MMISMedicaid Management Information System
    MQCMedicaid Quality Control
    MSA (group)Metropolitan Statistical Area - a statistical standard classification designated and defined by the Federal Office of Management and Budget following a set of official published standards.
    MSIMedical Services Invoice
    NCPDPNational Council of Prescription Drug Programs
    NCQANational Committee for Quality Assurance
    NDCNational Drug Code
    NECSNational Electronic Claims Submission
    NFNursing Facility - a general nursing facility, county or hospital-based nursing facility, which is licensed by the Department of Health and enrolled in the Medical Assistance program.
    NISNursing Information System - the comprehensive automated database of nursing facility, resident and fiscal information needed to operate the Pennsylvania Case-Mix Payment System.
    NPDBNational Practitioner Data Bank
    NPINational Provider Identifier
    OBRAOmnibus Budget Reconciliation Act
    OCDELOffice of Child Development and Early Learning
    OCYFOffice of Children, Youth and Families
    ODPOffice of Developmental Programs
    OIMOffice of Income Maintenance
    OLTLOffice of Long Term Living
    OMAPOffice of Medical Assistance Programs
    OMDOffice of the Medical Director
    OMHSASOffice of Mental Health and Substance Abuse Services
    OPTIONSCommunity Based Long Term Care
    PAPrior Authorization
    PACEPennsylvania Adoption Cooperative Effort
    PACEPharmaceutical Assistance Contract for the Elderly
    PACSESPennsylvania’s Child Support Enforcement System
    PBMPharmacy Benefit Manager
    PCPPrimary Care Provider – A specific medical services provider responsible for providing primary care services and locating, coordinating, and monitoring other medical care and rehabilitative services on behalf of a Medical Assistance recipient.
    PDAPennsylvania Department of Aging
    PEProgram Exception – Exception to the normal MA fee schedule or process for various reasons.
    PERMPayment Error Rate Measurement
    PHPhysical Health
    PHC4Pennsylvania Healthcare Cost Containment Council
    PH-MCOPhysical Health Managed Care Organization – A Commonwealth-licensed risk-bearing entity which has contracted with the Department of Public Welfare to manage the purchase and provision of physical health services to Medical Assistance recipients.
    PMSPennsylvania Medical Society
    POSPoint of Sale
    POSNetPennsylvania Open Systems Network – The network that is used to access the Department’s computer system, and to send and receive files from the Department’s contractors. POSNet is an extended Ethernet LAN (Local Area Network). The selection of industry standard protocols means that the LAN capabilities can be extended statewide by using LANs, Metropolitan Area Networks (MANs), and Wide Area Networks (WANs).
    PPSProspective Payment System - Medicare's version of our case-mix reimbursement system.
    ProDURProspective Drug Utilization Review
    PROMISe™Provider Reimbursement Operations and Management Information System
    ProviderA person, firm, or corporation enrolled in the Pennsylvania Medical Assistance Program which provides services or supplies to Medical Assistance recipients.
    PRRProgram Revision Request
    PSRPlace of Service Review
    QAQuality Assurance
    QCQuality Control
    QMQuality Management
    QMBQualified Medicare Beneficiary
    RARemittance Advice – an explanation containing the status of claims processed during a particular period for providers. Remittance Advices are mailed to providers on a weekly basis.
    RecipientA person eligible to receive health-related services under the Medical Assistance Program in Pennsylvania.
    RetroDURRetrospective Drug Utilization Review
    RFPRequest for Proposal
    RIDSResolution Image Display System
    RNACRegistered Nurse Assessment Coordinator - an individual licensed as a registered nurse by the State Board of Nursing and employed by a nursing facility, and who is responsible for coordinating and certifying completion of the resident assessment.
    RRPRecipient Restriction Program
    RTFResidential Treatment Facility
    RUG-IIIResource Utilization Group Version III - a category-based resident classification system used to classify nursing facility residents into groups based on their characteristics and clinical needs.
    SCSCState Civil Service Commission
    SPBPSpecial Pharmaceutical Benefits Program - The SPBP is a unique program that provides specific HIV/AIDS drugs and several atypical antipsychotic drugs for low and moderate income individuals with a diagnosis of HIV/AIDS or schizophrenia. Medical Assistance clients with drug benefits through the regular fee-for-service program or MA Managed Care Organizations are NOT eligible for SPBP coverage. The HIV/AIDS piece of the program is usually known as AIDS Drug Assistance Program or ADAP in other states.
    SPOCSingle Point of Contact
    SSASocial Security Administration
    SSISupplemental Security Income - Persons permanently disabled (must last at least 12 months) as determined by the Social Security Administration may qualify for this.
    SSNSocial Security Number
    STDSexually Transmitted Disease
    SURSSurveillance and Utilization Reporting System - a computerized reporting system used to detect potential fraud and abuse of Medical Assistance providers and recipients.
    TANFTemporary Assistance for Needy Families
    TCMTargeted Case Management
    TINTax Identification Number
    Total Facility CMITotal Facility Case Mix Index - the arithmetic mean case mix index of all residents regardless of the resident's sources of funding.
    TPLThird Party Liability
    UB-92 (form)Unified Billing 1992 (form) – used for billing Pennsylvania Medical Assistance for Inpatient services
    UMRUtilization Management Review - an audit conducted by the Department's medical and other professional personnel to monitor the accuracy and appropriateness of payments to nursing facilities to determine the necessity for continued stay of residents.
    VTVoucher Transmittal
    WANWide Area Network
    WICWomen, Infants and Children (program)
    YTDYear to Date