Terms and Definitions - JE Part B
Terms and Definitions
| Term | Definition |
|---|---|
| Accredited Provider/Supplier | A supplier that has been accredited by a CMS-designated accreditation organization. |
| Adjudicate | The process of determining payment or denial of a claim. |
| Advanced Diagnostic Imaging Services (ADI) | Any of the following diagnostic services:
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| Advanced Life Support | Level 1 - Transportation by ground ambulance vehicle, medically necessary supplies and services, and either an ALS assessment by ALS personnel or the provision of at least one ALS intervention. Level 2 - Either transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least three medications by intravenous push/bolus or by continuous infusion, excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer's Lactate); or transportation, medically necessary supplies and services, and the provision of at least one of the seven ALS procedures specified in § 414.605. |
| Air Ambulance | Fixed-Wing and Rotary-Wing (See § 414.605 for specific definitions of fixed-wing and rotary-wing). |
| Ambulance Services | As stated in 42 CFR § 410.40, there are several types of ambulance services covered by Medicare. They are generally defined in § 414.605 as follows:
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| Ambulatory Surgical Center (ASC) | Facility where outpatient surgical procedures are performed. Can bill Medicare once approved by the State Agency and CMS. |
| Applicant | The individual practitioner/provider/supplier who is applying for enrollment into the Medicare program. |
| Approve/Approval | The enrolling provider or supplier has been determined to be eligible under Medicare rules and regulations to receive a Medicare billing number and be granted Medicare billing privileges. |
| 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 non-participating Medicare providers who may accept assignment on a claim-by-claim basis. |
| Authorized Official (AO) | 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. |
| Basic Life Support (BLS) | Transportation by ground ambulance vehicle and medically necessary supplies and services, plus the provision of BLS ambulance services. The ambulance must be staffed by an individual who is qualified in accordance with state and local laws as an emergency medical technician-basic (EMT-Basic). |
| Billing Agency | An entity that furnishes billing and collection services on behalf of a provider or supplier. A billing agency is not enrolled in the Medicare program. A billing agency submits claims to Medicare in the name and billing number of the provider or supplier that furnished the service or services. In order to receive payment directly from Medicare on behalf of a provider or supplier, a billing agency must meet the conditions described in § 1842(b)(6)(D) of the Social Security Act. (For further information, see CMS Publication 100-04, chapter 1, section 30.2.4.) |
| Board Certified | Certified in a provider's particular specialty by the appropriate state board. This certification is not required by Medicare Part B for physicians and some Non-Physician specialties. |
| CMS-Approved Accreditation Organization | An accreditation organization designated by CMS to perform the accreditation functions specified. |
| 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. |
| Change in majority ownership | This occurs when an individual or organization acquires more than a 50 percent direct ownership interest in a home health agency (HHA) during the 36 months following the HHA's initial enrollment into the Medicare program or the 36 months following the HHA's most recent change in majority ownership (including asset sales, stock transfers, mergers, or consolidations). This includes an individual or organization that acquires majority ownership in an HHA through the cumulative effect of asset sales, stock transfers, consolidations, or mergers during the 36-month period after Medicare billing privileges are conveyed or the 36-month period following the HHA's most recent change in majority ownership. |
| Change of ownership (CHOW) | Defined in 42 CFR §489.18 (a) and generally means, in the case of a partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree otherwise, as permitted by applicable State law. In the case of a corporation, the term generally means the merger of the provider corporation into another corporation, or the consolidation of two or more corporations, resulting in the creation of a new corporation. The transfer of corporate stock or the merger of another corporation into the provider corporation does not constitute a change of ownership. |
| Claim | A request to a carrier by a beneficiary, or provider acting on behalf of the beneficiary, for payment of benefits under Medicare. |
| Clinical Laboratory Improvement Amendments (CLIA) | Clinical Laboratory Improvement Amendments of 1988. Regulation that applies to laboratories that tests human specimens for the diagnosis, prevention, treatment of any disease or impairment, or the assessment of the health of human beings. CLIA mandates that virtually all laboratories, including physician office laboratories, meet applicable Federal requirements and have a CLIA certificate in order to operate. |
| CMS Central Office (CO) | CMS main office is located in Baltimore, MD. |
| 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, revalidation, 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) unless the reassigning provider is a Physician Assistant. Physician Assistants are required to submit a CMS-855I application. |
| 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, revalidation, and voluntary deactivation of billing number. The CMS-855I is the only form in which a Physician Assistant (PA) can establish employment arrangement(s), change information, or terminate employment arrangement(s). |
| 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, edit primary practice information, and terminate a current reassignment. |
| Contractor | Organization contracted to process claims covered under Part B of Medicare. |
| Deactivate | The provider or supplier's billing privileges were stopped, but can be restored upon the submission of updated information. |
| Delegated Official (DO) | 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, a partner, an officer or director of the provider, or be a W-2 managing employee of the provider or supplier. |
| Deny/Denial | The enrolling provider or supplier has been determined to be ineligible to receive Medicare billing privileges. |
| 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. |
| Enroll/Enrollment | The process that Medicare uses to establish eligibility to submit claims for Medicare-covered items and services and the process that Medicare uses to establish eligibility to order or certify Medicare-covered items and services. |
| Enrollment Application | A paper CMS-855 enrollment application or the equivalent electronic (web) enrollment process approved by the Office of Management and Budget (OMB). |
| Final Adverse Action | One or more of the following actions:
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| 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 Partnerships (LLPs), Partnerships, Non-Profit Organizations, and Government Owned Entities must enroll as a group. |
| Health Professional Shortage Area (HPSA) | HPSAs are geographic areas, or populations within geographic areas, that lack sufficient health care providers to meet the health care needs of the area or population. HPSAs identify areas of greater need throughout the United States (U.S.) so that limited resources can be directed to those areas. Areas are designated as HPSAs by the Health Resources and Services Administration (HRSA) based on census tracts, townships, or counties. Designations are made for primary care, dental, and mental health. The CMS provides a 10 percent bonus payment when physicians furnish Medicare-covered services to beneficiaries in a geographic HPSA. The bonus is paid quarterly and is based on the amount paid for professional services. |
| Independent Diagnostic Testing Facility (IDTF) | An IDTF is a facility that is independent both of an attending or consulting physician's office and of a hospital. However, IDTF general coverage and payment policy rules apply when an IDTF furnishes diagnostic procedures in a physician's office (see 42 Code of Federal Regulations (CFR) 410.33(a)(1)). Effective for diagnostic procedures performed on or after March 15, 1999, Medicare Administrative Contractors (MACs) pay for diagnostic procedures under the Medicare Physician Fee Schedule (MPFS) when performed by an IDTF. An IDTF may be a fixed location or a mobile entity. It is independent of a physician's office or hospital. |
| Initial Enrollment | A provider or supplier must submit an initial enrollment application if they are:
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| Institutional Provider | For purposes of the Medicare application fee only - any provider or supplier that submits a paper Medicare enrollment application using the Form CMS-855A, Form CMS-855B (not including physician and non-physician practitioner organizations), Form CMS-855S or associated Internet-based Provider Enrollment, Chain and Ownership System (PECOS) enrollment application. |
| Interpreting Physician | Physicians who interpret diagnostic tests that may be billed by an IDTF. |
| Intensive Cardiac Rehabilitation (ICR) | ICR programs must be approved by CMS through the national coverage determination (NCD) process and must meet certain criteria for approval. Individual sites seeking to provide ICR services via an approved ICR program must enroll with their local Medicare contractor as an ICR program supplier. |
| Legal Business Name (LBN) | Name that is reported to the Internal Revenue Service (IRS). The LBN must be reported on the CMS-855 form and must match the name on the IRS documentation (e.g., CP-575, 147C Letter, quarterly tax coupon) submitted with the form. |
| Mammography Screening Center | A facility that is certified and responsible for ensuring that all screening mammography services furnished to Medicare beneficiaries meet the conditions and limitations for coverage of screening mammography services. To enroll in Medicare, a mammography screening center must have a valid provisional certificate, or a valid certificate, that has been issued by the Food and Drug Administration (FDA) indicating that the supplier meets the certification requirements. A copy of the supplier's FDA certification must be submitted with the CMS 855 form. |
| Managing Employee | 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 a 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 Roster Biller | An entity or individual that roster bills Medicare solely for mass immunizations. Can only bill for influenza virus vaccines, pneumococcal pneumonia vaccines (PPVs), and their administration. |
| Medicaid | Title XIX of the Social Security Act established a Federal/State entitlement program that pays for medical assistance for certain individuals and families with low incomes and resources. Each State administers its own program. |
| Medicare Identification Number | For Part A providers, the Medicare Identification Number (MIN) is the CMS Certification Number (CCN). For Part B suppliers other than suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), the MIN is the Provider Identification Number (PIN). For DMEPOS suppliers, the MIN is the number issued to the supplier by the National Provider Enrollment (NPE). (Note that for Part B and DMEPOS suppliers, the Medicare Identification Number may sometimes be referred to as the Provider Transaction Access Number (PTAN).) |
| National Provider Enrollment (NPE) | An entity that processes enrollment applications (CMS-855S) submitted by Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers. |
| National Provider Identifier (NPI) | A standard unique identifier for health care providers (including Medicare suppliers) and health plans that is assigned by the National Plan and Provider Enumeration System (NPPES). |
| Non-participating | A non-participating physician or supplier has the 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. A non-participating physician/supplier receives 5% less on reimbursement for all claims than a participating physician/supplier. |
| Noridian Healthcare Solutions, LLC | A subsidiary of Noridian Mutual Insurance Company® Noridian is the A/B Medicare Administrative Contractor (MAC) for Jurisdiction E and Jurisdiction F Noridian is the DME MAC for Jurisdiction D
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| Open 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. |
| Operational | Under 42 CFR §424.502 - means that the provider or supplier has a qualified physical practice location; is open to the public for the purpose of providing health care related services; is prepared to submit valid Medicare claims; and is properly staffed, equipped, and stocked (as applicable, based on the type of facility or organization, provider or supplier specialty, or the services or items being rendered) to furnish these items or services. |
| Open Enrollment Period | The timeframe in which a physician or supplier may choose to change their participation status with Medicare. Typically, physicians/suppliers have 45 days before the beginning of each new calendar year to either submit a letter requesting to become a non-participating physician/supplier, or become a participating physician/supplier by completing the CMS-460 Medicare Participating Physician or Supplier Agreement distributed with the Medicare Physician Fee Schedule (MPFS) each November. |
| Owner | Any individual or entity that has any partnership interest in, or that has 5 percent or more direct or indirect ownership of, the provider or supplier as defined in sections 1124 and 1124(A) of the Social Security Act. |
| Ownership or Investment Interest | Under 42 CFR § 411.354(b) - means an ownership or investment interest in the entity that may be through equity, debt, or other means, and includes an interest in an entity that holds an ownership or investment interest in any entity that furnishes designated health services. |
| Paramedic ALS Intercept Services (PI) | Per § 414.605, EMT-Paramedic services furnished by an entity that does not furnish the ground transport, provided that the services meet the requirements in § 410.40(c). PI typically involves an arrangement between a BLS ambulance supplier and an ALS ambulance supplier, whereby the latter provides the ALS services and the BLS supplier provides the transportation component. |
| Participating | A participating physician or supplier is one who voluntarily enters into an agreement to accept assignment for all Medicare patient covered services as payment in full. Medicare's payment will be made directly to the participating physician/supplier. The physician/supplier may collect applicable deductible and coinsurance payments from the beneficiary. |
| Pharmacies | Pharmacies typically enroll with the National Supplier Clearinghouse via the Form CMS-855S; however, there are certain covered drugs that are billed through the physician fee schedule and not the schedule for durable medical equipment, prosthetics, orthotics and supplies. These drugs must be billed to the A/B MAC, meaning that the pharmacy must enroll with the A/B MAC via the Form CMS-855B. |
| Physician | A doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor, as defined in section 1861(r) of the Social Security Act. |
| Portable X-Ray Suppliers (PXRS) | To qualify as a portable x-ray supplier (PXRS), an entity must meet the conditions for coverage discussed in 42 CFR § 486.100-110. A PXRS can be simultaneously enrolled as a mobile IDTF, though they cannot bill for the same service. A PXRS requires a State survey, while a mobile IDTF does not (although an IDTF requires a site visit). |
| Provider | A hospital, Critical Access Hospital, Skilled Nursing Facility, Comprehensive Outpatient Rehabilitation Facility, Home Health Agency, or a hospice that has in effect an agreement to participate in Medicare; or a clinic, rehabilitation agency, or public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services; or a community mental health center that has in effect a similar agreement but only to furnish partial hospitalization services. |
| 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. |
| Provider Transaction Access Number (PTAN) | A PTAN is a Medicare-only number issued to providers by MACs upon enrollment to Medicare. The PTAN is used to authenticate the provider when using MAC self-help tools such as the Interactive Voice Response (IVR) phone system, internet portal, and on-line application status. If a provider or supplier has relationships with one or more medical groups or practices or with multiple Medicare contractors, separate PTANs are generally assigned. |
| Psychologist (Clinical) | Clinical psychologists are authorized under the Medicare program to furnish "physician" services that fall under their state scope of practice and have services furnished as an incident to their own personal professional services without physician supervision, involvement or oversight. Clinical psychologists can perform diagnostic psychological and neuropsychological tests without a physician or authorized non-physician practitioner's order. In order to enroll in Medicare, a Clinical Psychologist must meet the following requirements:
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| Psychologist Practicing Independently | Independently practicing psychologists are authorized to bill the program directly solely for diagnostic psychological and neuropsychological tests that have been ordered by a physician, clinical psychologist or non-physician practitioner who is authorized to order diagnostic tests. In order to enroll in Medicare, a Psychologist Practicing Independently must meet the following requirements:
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| Radiation Therapy Centers (RTC) | Under 42 CFR § 410.35, Medicare Part B pays for X-ray therapy and other radiation therapy services, including radium therapy and radioactive isotope therapy, and materials and the services of technicians administering the treatment. Radiation therapy centers (RTCs) may receive reassigned benefits. An RTC need not separately enroll as a group practice in order to receive them. |
| Reactivation | The process a provider or supplier uses to reactivate Medicare billing privileges. To reactive a provider/supplier's Medicare billing privileges, a CMS-855 reactivation application or Reactivation Certification Package (RCP) must be submitted. Upon approval, a new PTAN will be issued and the effective date of the new PTAN will be the date the contractor received the CMS 855 application or RCP. |
| Reassignment | An individual physician, non-physician practitioner, or other supplier has granted a Medicare-enrolled provider or supplier the right to receive payment for the physician, non-physician practitioner or other supplier services. |
| Reject/Rejected | The provider or supplier's enrollment application was not processed due to incomplete information or that additional information or corrected information was not received from the provider or supplier in a timely manner. |
| Revalidation | Medicare providers and suppliers must resubmit and recertify the accuracy of their enrollment information every five years to maintain Medicare billing privileges. |
| Revoke/Revocation | The provider or supplier's billing privileges are terminated. |
| Specialty Care Transport (SCT) | Inter-facility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area (e.g., nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.) |
| Sole Proprietorship | A business as a Sole Proprietorship must meet all of the following criteria:
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| Sole Owner | A sole owner is a physician or practitioner who: (1) is the sole owner of a professional corporation, professional association, or limited liability company, and (2) will bill Medicare through this business entity. |
| Tax Identification Number (TIN) | A number that an individual or organization uses to report tax information to the IRS, such as a SSN or EIN. |
Last Updated Dec 09 , 2023
