Terms and Definitions

Term Definition
Ambulatory Surgical Center (ASC) Facility where outpatient surgical procedures are performed. The facility must be certified by the CMS Regional Office.
Annual Participation Enrollment When a provider is able to enroll or terminate their status as a participating provider. The period begins around mid-November of each year.
Applicant The individual practitioner/provider/supplier who is applying for Medicare enrollment.
Assignment A provider agrees to accept payment directly from Medicare for the covered services provided. The provider may bill the beneficiary for the 20% coinsurance, the deductible (if applicable) and any service(s) not covered by Medicare Part B. Medicare participating providers must accept assignment on all claims and receive a higher reimbursement than nonparticipating Medicare providers who may accept assignment on a claim-by-claim basis.
Authorized Official An appointed official (e.g., chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization's status in the Medicare program and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
Bankruptcy When a provider/supplier files for protection in a Federal bankruptcy court, it may choose, with the permission of the court, to cease operations (Chapter 7) or reorganize (Chapter 11). When a provider/supplier files under Chapter 7, it will liquidate its assets and cease operations and must notify the Medicare contractor of this action. When the assets are sold to a different entity, that entity must enroll with the Medicare contractor if it wishes to bill the Medicare program.
Billing Agency A company that the applicant contracts with to prepare or to edit the content of the claim.
Board Certified Certified in a provider's particular specialty by the appropriate state board. This certification is not required by Medicare B.
Center for Medicare and Medicaid Services (CMS) Formerly known as the Health Care Financing Administration (HCFA). The government agency within the Department of Health and Human Services responsible for oversight of the Medicare and Medicaid programs.
CMS Central Office (CO) CMS main office in Baltimore, MD.
Clinical Laboratory Improvement Amendments (CLIA) Clinical Laboratory Improvement Amendments of 1988. Regulation that applies to labs that examines Human specimens for the diagnosis, prevention or treatment of any disease or impairment or, or the assessment of the health of, human beings. A CLIA number is assigned to any provider that will be rendering laboratory services. That provider receives a CLIA certificate from the state CLIA agency.
CMS 855B - Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers

Enrollment application for health care suppliers. This form is for physician(s), non-physician practitioner(s) and other health care providers/suppliers who form a practice together and bill Medicare as a single supplier. This includes partnerships, groups, organizations, and corporations.

Reasons for submittal of this application: initial enrollment (new), reactivation, change of information, and voluntary termination of billing number.

If a supplier has individual practitioners, each member of the supplier must enroll as an individual (using the Application for Individual Health Care Practitioners, CMS 855I). Once the individual practitioner is enrolled, he or she can enroll as a member of an organization. When joining an organization every member of the organization must complete a copy of the CMS 855R (Individual Reassignment of Benefits).
CMS 855I - Medicare Enrollment Application - Physicians and Non-Physician Practitioners

Enrollment application for individual health care practitioners. This form is for physicians or non-physician practitioners who render medical services to Medicare beneficiaries and submits claims for the services rendered.

Reasons for submittal of this application: initial enrollment (new), reactivation, change of information, and voluntary deactivation of billing number.
CMS 855R - Medicare Enrollment Application - Reassignment of Medicare Benefits

Enrollment application for individual health care practitioners to reassign Medicare benefits. This form is to be completed for an individual practitioner who will be reassigning his or her benefits to an eligible provider or supplier.

Reasons for submittal of this application: add a new reassignment and terminate a current reassignment.
Contractor Organization contracted to process claims covered under Part B of Medicare
Delegated Official Any individual who is delegated, by the "Authorized Official," the authority to report changes and updates to the enrollment record. The delegated official must be an individual with 5 percent ownership interest in, or be a W-2 managing employee, of the provider or supplier.
Doctor of Chiropractic (DC) Licensed practitioner who treats spinal subluxation through manual manipulation.
Doctor of Dental Science (DDS) Licensed practitioner who treats the teeth, oral cavity, and associated structures.
Doctor of Medicine (MD) Licensed practitioner of medicine and/or surgery who has received the degree of doctor of medicine from a medical school.
Doctor of Osteopathy (DO) Licensed practitioner of medicine and/or surgery who has received the degree of doctor of medicine from a medical school
Doctor of Podiatry Medicine (DPM) Doctor practicing in the branch of medicine dealing with ailments of the foot.
Durable Medical Equipment (DME) Contractor

DME Contractors process claims for durable medical equipment, prosthetics, orthotics and supplies.

An item is considered durable medical equipment if it meets the following criteria: 1) it must be durable enough to withstand repeated use, 2) it must be primarily and customarily manufactured to serve medical purpose and 3) it must not be useful in the absence of illness or injury.

Noridian has the Jurisdiction D (JD) contract. https://med.noridianmedicare.com/web/jddme/
Fiscal Intermediary (FI) Private insurance organization which contracts with the Federal Government to Medicare A payment for services by hospitals, skilled nursing facilities, hospice, and home health agencies paid through the Medicare hospital insurance program. (Part A). Noridian is the Medicare Part A Fiscal Intermediary for Minnesota.
Food and Drug Administration (FDA) Number Certification number assigned by the FDA for mammography screening services. Providers that receive an FDA number also receive a certificate.
Free Standing Independent clinic not owned/affiliated with a hospital.
Group A Group is formed when a provider/practitioner employs other healthcare practitioners for whom Medicare will be billed. Limited Liability Partnership's (LLPs), Partnerships, Non-Profit Organizations, and Government Owned Entities must enroll as a group.
Health Professional Shortage Area (HPSA) HPSA is an incentive payment program for physician types practicing in shortage areas as designated by State Health Department.
Incorporated Any entity other than a sole proprietorship. A corporation is an entity that is separate and distinct from its owners, who are called stockholders or shareholders. To form a corporation, various documents, such as articles of incorporation, must be filed with the State in which it wants to incorporate. Key characteristics of a corporation are: Limited Liability, Double taxation, Board of Directors/Management, Continuity of Existence, and State Jurisdiction. (i.e., Inc., PLLC, LLC, etc.)
Independent Provider A provider who has a practice where the provider is using a SSN as the tax identification number or using a non-incorporated or sole proprietor tax identification number.
Initial Enrollment

Enrolling in the Medicare program for the first time with a particular Medicare carrier under this tax identification number or

Already enrolled with a contractor but need to enroll in another contractor's jurisdiction or

Enrolled with a particular contractor but has a new tax identification number.
Interpreting Physician Physicians whose diagnostic test interpretations will be billed.
Legal Business Name Name that the Entity uses to report to the Internal Revenue Service (IRS). This name must be reported on the CMS 855 form and must match the name on the IRS documentation that is submitted with the Enrollment/Change forms.
Mammography Screening Center (MAMC) Must be certified by the Food and Drug Administration to be payable by Medicare Part B
Managing Employee A managing employee means a general manager, business manager, administrator, director, or other individual that exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier, either under contract or through some other arrangement, whether or not the individual is a W-2 employee of the provider or supplier.
Mass Immunization Biller A health care provider who roster bills Medicare solely for mass immunizations. Can only bill for influenza and pneumococcal vaccinations and administrations.
Medicaid Federal assistance program for the poor and disadvantaged established under Title XIX of the Social Security Act and administered by State government.
National Provider Identifier (NPI) The standard unique health identifier for health care providers (including Medicare suppliers) and is assigned by the National Plan and Provider Enumeration System (NPPES).
National Supplier Clearinghouse Number (NSC) Number uniquely identifies the applicant as a supplier of DME. It is a number used by suppliers on claim forms for billing to the DME for reimbursements.
Non-participating Provider has option to accept or not accept assignment on a claim-by-claim basis and may charge the beneficiary up to the limiting charge on non-assigned claims. The nonparticipating provider receives 5% less on reimbursement for all claims than a participating provider.
Noridian Noridian is the Medicare Part B Contractor for JF which contains Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming.
Open Enrollment Period The timeframe in which a provider/supplier may choose to change their Participation or NonParticipation status with Medicare. Typically, providers/suppliers have 45 days before the beginning of each new calendar year to either submit a letter requesting to become NonParticipating or to complete the Participation Agreement form distributed with the Medicare Physician Fee Schedule (MPFS) each November.
Participating A participating physician or supplier is one who voluntarily enters into an agreement to accept Medicare assignment for all Medicare patients covered services as payment in full. Medicare's payment will be made directly to the participating provider. The provider may collect applicable deductible and 20% coinsurance payments from the beneficiary.
Provider Institution, individual, or organization qualified to provide healthcare.
Provider Enrollment Chain Ownership System (PECOS)

PECOS supports the Medicare Provider and Supplier enrollment process by allowing registered users to securely and electronically submit and manage Medicare enrollment information.

https://pecos.cms.hhs.gov/pecos/login.do
Provider Transaction Access Number (PTAN) The PTAN is issued by a contractor and identifies the provider's name, credentials, group practice information, payee address, and claim history with the carrier. A single provider may have multiple PTANs with the same contractor depending on the number of employment arrangements or independent practices.
Psychologist (Clinical) Applicant must hold a doctoral degree in Psychology. There are three different types of doctoral degrees in Psychology that meet Medicare's requirements: Ph.D.-doctorate of Philosophy degree Psy.D.-doctorate of Psychology degree Ed.D.-doctorate of Education degree (must be in psychology)
Psychologist Billing Independently A psychologist billing independently is defined as: One who renders services free of the administrative and professional control on an employer such as a physician, institution, or agency, and who maintains office space at his/her own expense and furnishes services only in that space of the patient's home, and has the right to collect fees for the services rendered, and the patients treated are the psychologist's own patients.
Reactivation The process a provider uses to activate a deactivated PTAN. A PTAN can be deactivated for several reasons including: no billing activity in the last year, the provider has moved, a provider's medical license has expired, or the provider has left the group they practice in. To reactivate a PTAN, a provider may need to submit an updated CMS 855 form or certify the accuracy of their enrollment information already on file.
Reassignment An assignment to bill and receive payment for services furnished to a Medicare beneficiary, from a physician or other individual supplier, who can bill in his or her own name and billing number, to another person or entity that is enrolled in the Medicare program, as long as one of the exceptions to the prohibition against reassignment is met. The reassignment exceptions are discussed in the CMS Internet Only Manual Publication 100-04, Chapter 1, Sections 30.2-30.2.16; in the CMS regulations at section 424.80; and, in the law at section 1842(b((6) of the Social Security Act (SSA).
Revalidation

Per 42CFR 424.515, Medicare providers and suppliers must resubmit and recertify the accuracy of their enrollment information every five years to maintain Medicare billing privileges.

Also, providers who are ordering or referring Medicare patients must have a record in PECOS. Providers who have been enrolled in Medicare but are not in the PECOS system will need to send in a revalidation application to prevent claims from denying beginning January 3, 2011.
Supervising Physician Physician responsible for the direct and ongoing oversight of the quality of the testing performed, the proper operation and calibration of equipment used to perform tests, and/or the qualifications of nonphysician IDTF personnel who use the equipment.
Tax Identification Number (TIN)

A number that an individual or organization uses to report tax information to the IRS, such as a Social Security Number (SSN) or Employer Identification Number (EIN).

This number is also reported in Item 25 of the CMS-1500 claim form.

 

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