Glossary of Medicare Terminology

Abuse Improper or excessive use of program benefits or services by providers or consumers. Abuse can occur, intentionally or unintentionally, when services are used which are excessive or unnecessary; which are not the appropriate treatment for the patient’s condition; when cheaper treatment would be as effective; or when billing or charging does not conform to requirements. It should be distinguished from fraud, in which deliberate deceit is used by providers or consumers to obtain payment for services which were not actually delivered or received, or to claim program eligibility. Abuse is not necessarily either intentional or illegal.

Accounts Receivable An account set up to collect money from a beneficiary or provider when there has been a Medicare overpayment. Any payments received from the beneficiary or provider will be applied to the AR until it is satisfied.

Accredited Hospital A hospital approved by the Joint Commission on Accreditation of Health Organizations (JCAHO).

Acute Care A level of care that can be rendered only in a hospital.

Acute Disease A disease which is characterized by a single episode of fairly short duration from which the patient returns to his normal or previous state and level of activity. Acute diseases are distinguished from chronic diseases.

Ad Hoc Request A request to provide non-production support. This support may be in the form of one time updates to production files or the creation of specific one-time or as needed output reports.

Adjudicated Claims A claim that has been fully processed though the system, has been determined to be payable or denied, and for which notification via and EMOB or a remittance advice indicating payment or denial has been mailed.

Adjudication Determination of payment allowance on a claim.

Adjustment Bill/Claim A correction bill/claim subsequent to an original bill/claim which was incorrectly processed or which was incomplete and could not be processed.

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

Admission Entry to a hospital as a patient.

Admitting Physician The physician responsible for admission of a patient to a hospital or other inpatient health facility. Some facilities have all admitting decisions made by a single physician (typically a rotating responsibility) called an admitting physician.

Advance Directives Written documents stating how you want medical decisions made for you if you lose the ability to make decisions for yourself. The two most common advance directives are: Living Wills and Durable Powers of Attorney for Health Care.

Advance Notice When the provider believes that Medicare will not make payment due to a service being “not reasonable and necessary,” an advance written notice to the beneficiary can protect the provider from liability.

Affiliated Hospital One which is affiliated in some degree with another health program, usually a medical school

Age Discrimination in Employment Act of 1967 (ADEA) As amended in 1978, ADEA requires employers with 200 or more employees to offer older active employees under age 70 who are eligible for Medicare (and their spouses if they are also under age 70) the same health insurance coverage that is provided to younger employees.

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.

Allied-Health Personnel Specially trained health workers other than physicians, dentists, podiatrists and nurses. The term has no constant or agreed upon meaning: sometimes meaning all health workers who perform tasks which must otherwise be performed by a physician; and sometimes referring to health workers who do not usually engage in independent practice.

Allowed Amount Either the amount billed for a medical service or the amount determined payable by Medicare, whichever is the lesser figure.

Alternative Delivery Systems (ADS) A method of providing a comprehensive health care program to subscribers other than the traditional fee-for-service method (e.g., HMOs, PPOs).

Ambulatory Care Health services which are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients.

Ambulatory Surgery A large, though limited, range of procedures using operative and anesthesia techniques that allow the patient to recuperate at home, rather than in the hospital, immediately following the operation.

Ambulatory Surgical Center (ASC) a distinct entity which operates exclusively to provide outpatient surgical services.

American Association of Retired Persons A service and lobbying group composed of people age 50 and over that has the Medicare program among its concerns. Commonly known as the AARP.

American Hospital Association (AHA) A voluntary association of hospitals organized for the purpose of helping hospitals provide better patient care.

American Medical Association (AMA) A public service organization dedicated to the advancement of science and medicine and betterment of the public health and welfare.

Americans with Disabilities Act A law enacted in 1990 that prohibits discrimination against persons with disabilities in such areas as public accommodations and terms and conditions of employment.

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 Charge A charge used on institutional claims for any item except hospital and physician fees, such as drug, lab, or X-ray charges.

Ancillary Services Hospital services other than room and board, and professional services. They may include X-ray, drug, laboratory or other services.

Anesthesiologist or Anesthetist A person who administers anesthetics for surgery and diagnostic procedures. An anesthesiologist is always a holder of the M.D. or D.O. degree; an anesthetist may be a nurse-anesthetist or an anesthesia technician.

Appeal Requests Written statements that convey an explicit or implicit request for review of the initial determination, or a dissatisfaction with the most recent determination.

Approved Charge The amount that Medicare has determined is appropriate for payment to a physician for a service, based on his and his colleagues’ histories of charge. See Usual, customary, and reasonable reimbursement system.

Assigned Claim A Part B claim for physician or supplier services where the provider agrees to accept the Medicare allowed charge as payment in full.

Assignment Payment for covered services goes directly to the physician.

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

Attending Physician The physician primarily responsible for the care of a beneficiary with respect to a particular illness or injury. Also a doctor with staff privileges at a hospital who treats patients there. Usually applied to physicians on the staff of a teaching hospital who have a role in teaching and supervising interns and residents.

Audio Response Unit (IVR) The computerized telephone answering service which allows a beneficiary or provider to check claim status using a touch tone telephone.