ACA (or PPACA) – Patient Protection and Affordable Care Act of 2010
ACHE – American College of Healthcare Executives (ACHE) an international professional society of 30,000 healthcare executives who lead our nation’s hospitals, healthcare systems, and other healthcare organizations. ACHE is known for its prestigious credentialing and educational programs and its annual Congress on Healthcare Management, which draws more than 4,000 participants each year. ACHE is also known for its journal, the Journal of Healthcare Management, and magazine, Healthcare Executive, as well as ground-breaking research and career development and public policy programs. ACHE’s publishing division, Health Administration Press, is one of the largest publishers of books and journals on all aspects of health services management in addition to textbooks for use in college and university courses.
ADA – American Dental Association (ADA) is a professional association of dentists committed to the public’s oral health, ethics, science and professional advancement.
ADA – The Americans with Disabilities Act (ADA) is a wide-ranging civil rights law that prohibits discrimination based on disability. It is similar to the Civil Rights Act of 1964, which makes it illegal to discriminate because of race, sex, religion, national origin and other characteristics.
ADC – Adult Day Care (ADC) provides daily structured programs in a community setting, with activities plus health-related and rehabilitation services for older adults who are physically or emotionally disabled and need a protective environment. Care is provided during daytime hours and the individual returns to his or her home for the night. Adult day care is offered at a special facility or as a service of another type of care facility, such as a nursing home or assisted living residence.
ADS – Alternate Delivery System (ADS) health services that are more cost-effective than inpatient, acute-care hospitals, such as skilled and intermediary nursing facilities, hospice programs and in-home services.
AFDC – Aid to Families with Dependent Children (AFDC) is a program administered and funded by Federal and State governments to provide financial assistance to needy families. In an average state, more than half (55 percent) of the total cost of AFDC payments are funded by the Federal government. The States provide the balance of these payments, manage the program and determine who receives benefits and how much they get.
AG – The Attorney General (AG) is the chief law officer of a country or state. Jim Hood is the Attorney General of the state of Mississippi.
AL – Assisted Living Waiver
ALOS – Average Length of Stay (ALOS) in hospitals it is calculated by dividing the sum of inpatient days by the number of patients within the diagnosis-related group category. Inpatient days are calculated by subtracting day of admission from day of discharge, so persons entering and leaving a hospital on the same day have a length of stay of zero.
AMA – The American Medical Association (AMA), is a professional physicians’ organization founded 1847. Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science. The AMA investigates alleged cases of medical quackery, engages in medical research on drugs, foods, cosmetics, and other substances, and sponsors health education programs. The organization also approves in-hospital doctor training programs; it was largely responsible for the upgrading of American medical education in the early 20th centunry. Other functions include monitoring professional ethics and supervising continuing medical education for physicians.
APCs – Ambulatory Payment Classifications
AR – Accounts Receivable (AR) is the area that funds are paid to reimburse Medicaid.
ARRA – American Recovery and Reinvestment Act
ARS – Automated Response System
ASC – An Ambulatory Surgical Center (ASC) is a licensed facility that is used mainly for performing outpatient surgery, has a staff of physicians, has continuous physician and nursing care by registered nurses and does not provide for overnight stays.
AWP – Any Willing Provider
BBA – The Balanced Budget Act (BBA) signed into law by the President on Aug. 5, 1997 contains the largest reductions in federal Medicaid spending in Medicaid since 1981. The legislation is projected to achieve gross federal Medicaid savings of $17 billion over the next five years and $61.4 billion over the next ten years.
BIP – Balancing Initiatives Program
BPM – Business Process Management
CAH – Critical Access Hospital (CAH) a rural limited medical services hospital that provides short-term inpatient and emergency hospital services.
CAP – Corrective Action Plan (CAP) documentation for implementing activities structured to remedy a problem, and what will happen if the problem is not resolved. Includes a specific time frame for the remedy to be implemented.
CCD – Continuity of Care Document (CCD) is a spreadsheet-based document containing the encoding, structure and semantics of a patient’s clinical summary document for exchange.
CCM – Certified Case Manager
CCO – Coordinated Care Organizations
CDC – The Centers for Disease Control (CDC) is an institution of epidemiological science that monitors and investigates health and disease in this country and serves as a resource for the world community.
CDT – The Current Dental Terminology (CDT) is a publication copyrighted by the American Dental Association (ADA) that lists codes for billing for dental procedures and supplies. The CDT is included in HCPCS level II.
CFR – Code of Federal Regulations
CG – Class Group Code required on the Medicaid claim form.
CHAMPUS – Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) a federally funded health program that provides beneficiaries with medical care supplemental to that available in military and Public Health Service (PHS) facilities.
CHIP – The Children’s Health Insurance Program (CHIP) is a joint federal and state program that provides health insurance coverage to low-income uninsured children.
CHIRPA – Comprehensive Health Insurance Risk Pool Association
CIM – Carrier Information Module (CIM) data on insurance companies with whom Medicaid beneficiaries have medical coverage.
CLIA – Clinical Laboratory Improvement Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988 establishing quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results regardless of where the test was performed. Centers for Medicare & Medicaid Services (CMS) assumes primary responsibility for financial management operations of the CLIA program.
CMHC – Community Mental Health Center (CMHC) a comprehensive mental health center which provides outpatient therapy and emergency mental health services.
CMN – Certificate of Medical Necessity (CMN) a form required by Medicare authorizing the use of certain medical services and equipment prescribed by a physician.
CMS – Center for Medicare and Medicaid Services is the federal agency which administers the Medicare program and works in partnership with the States to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards. In addition to these programs, CMS has other responsibilities, including the administrative simplification standards for the Health Insurance Portability and Accountability Act of 1996 (HIPPA), quality standards in health care facilities through its survey and certification activity, and clinical laboratory quality standards.
CMS 1500 – The CMS 1500 Claim Form is the basic form prescribed by CMS for the Medicare program for claims from physicians and suppliers, except for ambulance services. It has also been adopted by the Office of Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and has received the approval of the American Medical Association (AMA) Council on Medical Services. Providers may use these instructions for completing this form. The CMS-1500 form has space for physicians and suppliers to provide information on other health insurance. This information is used to determine whether the Medicare patient has other coverage which must be billed prior to Medicare payment, or whether there is a Medigap policy under which payments are made to a participating physician or supplier.
CNP or NP – Certified Nurse Practitioner (CNP) is a registered nurse (RN) who has completed an advanced training program in a medical specialty such as pediatrics or internal medicine. An NP may function as a primary direct provider of health care and prescribe medications. An NP may fill another role such as in research rather than in patient care.
COB – Coordination of Benefits (COB) a common provision in most benefit plans. It applies when a member has more than one health coverage plan in effect at the time services are rendered.
COBRA – Consolidated Omnibus Budget Reconciliation Act of 1985 a federal law, enforced by the US Department of Labor, Pension and Welfare Benefits Administration, which provides continuation of group health coverage that otherwise might be terminated. The law contains provisions giving certain former employees, retirees, spouses and dependent children the right to temporary continuation of health coverage at group rates.
COS – Category of Service (COS) code required on the Medicaid claim form.
CPT – Current Procedural Terminology (CPT) book contains codes approved for use by medical providers to request payment for a particular medical service.
CQM – Clinical Quality Measures
CR – Carrier Term (CT) applied to a medical insurance company with who a Medicaid beneficiary has coverage.
CRH – Center for Rural Health
CRNA – Certified Registered Nurse Anesthetist an advanced practice nurse who administers anesthesia.
CRRN – Certified Rehabilitation Registered Nurse
CSR – Computer System Request (CSR) the means by which requests from authorized Medicaid staff for enhancements and modifications to the MMIS are submitted to the Fiscal Agent.
DAC – Disabled Adult Child
DCLH – Disabled Child Living at Home (DCLH), better known as the Katie Beckett Program, the Disabled Child Living at Home is a special program where children who do not meet eligibility for other Medicaid programs due to their parents’ high income or assets can qualify for Medicaid if the child meets certain defined criteria.
DFA – The Mississippi Department of Finance & Administration (DFA) helps the Governor, State agencies, and State Legislators provide effective, efficient, and fiscally sound government to the citizens of Mississippi. DFA assists agencies in maintaining adequate internal controls and efficient management practices. DFA provides quality, cost effective services such as building construction, acquisition and maintenance, insurance, and purchasing and travel. DFA builds an Executive Budget that reflects the Governor’s priorities.
DHA – Delta Health Alliance
DHS – Mississippi Department of Human Services (DHS), is the state agency which provides services for people in need and promotes the welfare of children and families.
DME – Durable Medical Equipment (DME) is equipment that can be used over and over again; is ordinarily used for medical purposes; and is generally not useful to a person who isn’t sick, injured or disabled.
DO – Doctor of Osteopathy is a doctor with a degree in osteopathy which is therapy based on the assumption that restoring health is best accomplished by manipulating the skeleton and muscles.
DOB – Date of Birth, the month/day/year on which a person was born.
DOD – Date of Death, the date upon which a person’s death occurs.
DOI – Department of Insurance responsible for admitting, licensing, and regulating insurance companies as well as regulating the various kinds of insurance sold in the state, in addition to the companies and agents selling it.
DOM – Mississippi Division of Medicaid
DOS – Date of Service, is the date a beneficiary received a medical service.
DRG – Diagnosis Related Groups, is a system of classification of diagnoses and procedures based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).
DUR – Drug Utilization Review Board a quality assurance body which seeks to assure appropriate drug therapy to include optimal patient outcomes and appropriate education for physicians, pharmacists, and the patient
E&D – Elderly and Disabled
EDI – Electronic Data Interchange is the electronic transmission of structured data between organizations.
EFT – Electronic Funds Transfer is the transfer of money initiated through electronic terminal, automated teller machine, computer, telephone or magnetic tape.
EHR – Electronic Health Records
EI/TCM – Early Intervention/Targeted Case Management an active, ongoing process that involves activities carried out by a case manager to assist and enable a child (up to three years old) enrolled and participating in the Mississippi Early Intervention Program gain access to needed medical, social, educational and other services.
EMR – Electronic Medical Records
EOB – Explanation of Benefits (EOB) statement of the action taken on claims filed by medical providers for services rendered for the treatment of a patient.
EOMB – Explanation of Medicaid Benefits (EOMB) statement sent to a Medicaid beneficiary detailing services submitted/action taken on claims filed by Medicaid providers for services rendered to a Medicaid beneficiary.
EPO – Exclusive Provider Organization (EPO) limited healthcare provision: a health insurance plan that will reimburse the insured only for care received from particular providers.
EPrescribing – Electronic Prescribing, entails the process of electronically transmitting an error-free prescription from a prescriber to a pharmacy for fulfillment.
EPSDT – Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a free health care program for Mississippi’s children ages birth through 21 who are eligible for Medicaid. It provides a way for children to get medical exams, check-ups, follow-up treatment and special care they need to make sure they enjoy the benefits of good health.
eQHealth – eQHealth is the Utilization Review Organization contracted with the Division of Medicaid for the state of Mississippi.
ER – Emergency Room (ER), is a room in a hospital or clinic staffed and equipped to provide emergency care to persons requiring immediate medical treatment.
ESC – Electronic Submission Claims a claim that is submitted via electronic media.
EScript – State of Mississippi’s ePrescribing System
F&A – Fraud and Abuse
FA – Fiscal Agent
FAQ – Frequently Asked Questions (FAQ) are a collection of commonly asked questions regarding a particular subject and the answers to the questions.
FDA – The Food and Drug Administration (FDA) agency of the Public Health Service division of the U.S. Department of Health and Human Services is charged with protecting public health by ensuring that foods are safe and pure, cosmetics and other chemical substances harmless and products safe, effective and honestly labeled.
FFP – In accordance with section 1903(a) of the Act, a state with an approved Medicaid state plan may receive federal financial participation (FFP) for expenditures for medical assistance.
FFS – Fee for Service (FFS) pertaining to the charging of fees for specific services rendered in health care, as distinguished from participating in a prepaid medical practice.
FHA – Federal Health Architecture (FHA), an E-Government Line of Business initiative managed by the Office of the National Coordinator for Health IT. FHA was formed to coordinate health IT activities among the more than 20 Federal Agencies that provide health and healthcare services to citizens.
FNP – Family Nurse Practitioner
FP – Family Planning (FP), the concept or a program of limiting the size of families through the spacing or prevention of pregnancies.
FP – A Family Practice (FP) medical specialization in general practice, requiring training beyond that of general practice and leading to board certification.
FPW – Family Planning Waiver (FPW) a Medicaid program for women 15-44 years of age that covers selected family planning services and supplies.
FQHC – Federally Qualified Health Clinic (FQHC) is a center that provides health care to a medically under served populations.
GINA – Genetic Information Nondiscrimination Act of 2008
GUI – Graphical User Interface
HBE – Health Benefit Exchange
HCBS – Home and Community Based Services provides individualized assistance with daily living activities to people with disabilities through Medicaid’s optional personal care services program.
HCPCS – The Healthcare Common Procedure Coding System (HCPCS) is the required code set for substances, equipment, supplies and other items used in health care.
HDS – Health Data System
HEIDIS – Health Plan Employer Data and Information Set
HH – Home Health (HH) services cover a broad range of services including: high tech pharmacy services, skilled professional and paraprofessional services, custodial care, and medical equipment provided or delivered to the home. Most services must be ordered by a physician and must be medically necessary to maintain or improve a health condition. Generally, home health services are initiated when a loved one is no longer able to care for him or herself due to failing health or recent changes to their health.
HHA – A Home Health Agency (HHA) is a public or private agency that provides skilled nursing care, physical therapy, speech therapy and other therapeutic services in the patient’s home.
HHS – The Department of Health and Human Services (HHS) is the United States department that administers all federal programs dealing with health and welfare.
HIPAA – The Health Insurance Portability and Accountability Act of 1996 (HIPAA) consists of two Titles. Title I protects health insurance coverage for workers and their families when they change or lose their jobs. Title II requires the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and addresses the security and privacy of health information. HIPAA was first proposed with the simple objective to ensure health insurance coverage after leaving a job. In addition to these portability provisions, however, Congress added an Administrative Simplification section, with the goal of saving money in mind. The Administrative Simplification section was requested and supported by the health care industry because it standardized electronic transactions and required standard record formats, code sets, and identifiers.
HIT – Health Information Technology
HMA – Health Management Associates
HMO – A Health Management Organization (HMO) is group insurance that entitles members to services of participating hospitals and clinics and physicians.
HRSA – The Health Resources Services Administration (HRSA) is a research grant to collect and analyze data that describe the characteristics of the uninsured.
HSP – Hospice (HSP) used in terminology associated with beneficiary’s lock in segment for Home and Community Based Services.
IAPD – Implementation Advance Planning Document
ICD-10 – International Classification of Diseases, tenth revision
ICD-9-CM – International Classification of Diseases Ninth Edition Clinical Modification
ICD – International Classification of Diseases
ICF – An Intermediate Care Facility is a health care facility that provides care and services to individuals who do not need skilled nursing care, but whose mental or physical condition requires more than custodial care and services in an institutional setting.
ICF/MR – Intermediate Care Facilities for the Mentally Retarded or related conditions provides twenty-four hour supervision and training, and is regulated through requirements established by Medicaid.
ICN – An Internal Control Number (CN) is a unique identifier for a claim line assigned by the MMIS.
ICU – An Intensive Care Unit (ICU) is a hospital unit staffed and equipped to provide intensive care.
ID/DD – Intellectual Disabilities/ Developmental Disabilities Waiver
IDEA – Individuals with Disabilities Education Act (IDEA) is the federal law which safeguards a child with a disability’s right to a free and appropriate public education.
IEP – An Individualized Education Plan (IEP) is a written document that outlines a child’s education. As the name implies, the educational program should be tailored to the individual student to provide maximum educational benefit.
IFSP – Individualized Family Service Plan see EI/TCM
IHE – Integration the Healthcare Enterprise (IHE) is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. IHE promotes the coordinated use of established standards such as DICOIM and HL7 to address specific clinical needs in support of optimal patient care.
IHS – Indian Health Services
INFOSHP – Mississippi Information for State Health Policy Project turns valuable health statistics into workable information for state policy makers and is the focus of a national grant program of The Robert Wood Johnson Foundation called the Information for State Health Policy Program (InfoSHP). Seven states were awarded grants to improve the presentation of data in order to help policy makers make more informed decisions about health programs. The states which have received InfoSHP grants are Arkansas, California, Mississippi, New York, North Carolina, South Carolina and Wisconsin. To identify policy information needs in the area of Medicaid managed care, the National Office of Information for State Health Policy Program commissioned an opinion survey of policy makers in the seven InfoSHP grant states.
IP – Inpatient is a term for patients who receives lodging and food, as well as treatment, in a hospital or an infirmary.
IQH – Information and Quality Healthcare (Medicare QIO in Mississippi)
IT – Information Technology
IV&V – Independent Verification and Validation
IWG – Interagency Working Group
JCHO – The Joint Commission on Accreditation of Healthcare Organizations (JCHO) is the predominant health care standards-setting and accrediting organization in the U.S. Their mission is to continually improve the safety and quality of patient care by providing accreditation, education and consultation services.
LBO – Legislative Budget Office
LCSW – Licensed Certified Social Worker (LCSW) individuals having an education that includes a masters degree in social work (M.S.W.) and post M.S.W. supervised experience in clinical social work.
LOS – Length of Stay (LOS) is calculated by dividing the sum of inpatient days by the number of patients within the DRG category.
LPN – Licensed Practical Nurse
LTC – Long Term Care (LTC) includes any chronic or disabling condition which requires nursing care or constant supervision.
MAGI – Modified Adjusted Gross Income
MAO – Medical Assistance Only (MAO) is medical assistance for Aged or Disabled Medicaid beneficiaries residing in nursing facilities who pay part of the cost of their care with Medicaid paying the remaining amount.
MARS – Management and Administrative Reporting Subsystem
MCO – Managed Care Organization
MD – A physician, medical doctor
MDHS – Mississippi Department of Human Services (DHS), is the state agency which provides services for people in need and promotes the welfare of children and families.
MDMH – Mississippi Department of Mental Health provides a network of services to persons who experience problems with mental illness, alcohol and/or drug abuse/dependence, or who have mental retardation or developmental disabilities. Services are provided through an array of facilities and agencies operated and/or funded by the Department of Mental Health
MDRS – Mississippi Department of Rehabilitation Services is the state agency which provides services to Mississippians with disabilities. Programs and services assist individuals with disabilities to gain employment, retain employment and/or to live more independently.
MEDS – Mississippi Eligibility Determination System (MEDS) is the subsystem of the MMIS utilized by Medicaid staff charged with determining initial and ongoing eligibility for Medicaid applicants and beneficiaries.
MEDS/MEDSX – Medicaid Eligibility Determination System Expansion
MEDX – Medical Electronic Data Exchange
MEHRS/eScript – Medicaid Electronic Health Records System and ePrescribing System
MEMA – Mississippi Emergency Management Association is the state agency charged with emergency management preparedness, training, mitigation, response and recovery.
MES – Medicaid Enterprise Solution
MFCU – The Medicaid Fraud Control Unit (MFCU) is the law enforcement agency under the State Attorney General staffed by attorneys, auditors, and investigators trained in the complex subject of health care fraud. The Unit shares pertinent information with other state and federal agencies so that appropriate administrative sanctions can be implemented against health care providers who abuse the Medicaid program or residents of health care facilities.
MHA – The Mississippi Hospital Association (MHA) is a statewide trade organization that assists member hospitals in effectively serving the health care needs of Mississippi through advocacy, representation, information, education and services.
MHCA – Mississippi Health Care Association
MHCC – Mississippi Health Care Commission Certified
MID – Medicaid Id Number
MississippiCAN – Mississippi Coordinated Access Network
MITA – The Medicaid Information Technology Architecture (MITA) initiative is a national framework designed to support improved systems development and healthcare management for the Medicaid enterprise.
MMA – The Medicare Modernization Act (MMA) calls for Medicare to pay for two drugs in each therapeutic class.
MMIS – The Medicaid Management Information Systems (MMIS) is the data files, computer systems and computer subsystems which handle the electronic administration processes of the Medicaid program.
MN – Medical Necessity (MN) or Medically Necessary Analysis determines appropriateness of services rendered to ensure quality of care.
MNR – Medical Necessity Referral (MNR) is a nurse who has enough training to be licensed by a state to provide routine care for the sick.
MPHCA – Mississippi Primary Health Care Association (MPHCA) is a membership organization representing the state’s Community Health Centers and other community based health care providers. MPHCA is a nonprofit 501 (c)(6) organization.
MPIP – Mississippi Provider Incentive Program
MR/DD – Mental Retardation and/or Developmental Disabilities (MR/DD) legislation granted the Secretary of the United States Department of Health and Human Services (DHHS) authority to waive federal regulations that previously limited Medicaid reimbursement to institutional long-term care settings. No other change in federal law to date surpasses this legislation in terms of its significance for reforming the delivery of long-term care services.
MS – Medical Supply (MS) are goods and equipment utilized for the treatment and care of persons with an illness, disease or disability.
MS SLR – Mississippi State Level Registry
MSDH – Mississippi Department of Health is the state agency which oversees health services and administers health programs, regulation and licensure and vital records and statistics.
MTM – Medical Transportation Management
MYPAC – Mississippi Youth Programs Around the Clock
NAAC – Net Average Allowable Costs
NAMI – National Alliance for the Mentally Ill (NAMI) is a nonprofit, grassroots, self-help, support and advocacy organization of consumers, families and friends of people with severe mental illnesses, such as: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, panic and other severe anxiety disorders, autism and pervasive developmental disorders, attention deficit/hyperactivity disorder, and other severe and persistent mental illnesses that affect the brain.
NASMD – National Association of State Medicaid Directors (NASMD) is a bipartisan, professional, nonprofit organization of representatives of state Medicaid agencies (including the District of Columbia and the territories). The primary purposes of NASMD are: to serve as a focal point of communication between the states and the federal government, and to provide an information network among the states on issues pertinent to the Medicaid program.
NDC – The National Drug Code (NDC) system was originally established as an essential part of an out-of-hospital drug reimbursement program under Medicare. The NDC serves as a universal product identifier for human drugs.
NET – Non-Emergency Transportation is prearranged transportation provided for medical appointments.
NF – A Nursing Facility (NF) is a nursing home which provides nursing and/or rehabilitation services to patients who need medical care that cannot be provided in the patient’s home.
NIST – National Institute of Standards Technology
NP – A Nurse Practitioner (NP) is a registered nurse who has received special training and can perform many of the duties of a physician.
NPI – National Provider Identifier
O&P – Orthotics and Prosthetics (O&P) is the surgical or dental specialty concerned with the design, construction and fitting of an artificial device to replace a missing part of the body or to support or brace weak or ineffective joints or muscles.
OBRA – On Nov. 5, 1990 the President signed into law the Omnibus Budget Reconciliation Act of 1990 (OBRA 90), P.L. 101-508.
OIG – The Office of the Inspector General is the investigative arm of the Federal Trade Commission.
ONC – The Office of the National Coordinator of Health Information Technology (ONC) is an office under the U.S. Department of Health and Human Services established as part of the HITECH Act of 2009 to support the adoption of health information technology to improve healthcare.
OP – A hospital Out Patient (OP) is a patient who receives treatment, in a hospital or an infirmary but no lodging and food.
OSHA – Occupational Safety and Health Act is a government agency in the Department of Labor to maintain a safe and healthy work environment.
P&T – The Pharmacy & Therapeutics (P&T) Committee conducts in-depth evaluations of available drugs and recommend appropriate drugs for preferred status and makes recommendations to the Medicaid Executive Director regarding prior authorization criteria for these drugs and classes.
PA – Physician’s Assistant
PA – Prior Authorization (PA) is certification for drugs and medical services which exceed the benefit limits afforded under the Medicaid program.
PaaS – Platform as a Service
PAC – Pricing Action Code (PAC) is a code required on the Medicaid claim form.
PAM – Payment Accuracy Measurement (PAM) Project/Grant is a method to estimate improper payments for the Medicaid program in response to the Government Performance and Results Act of 1993 (GPRA), Public Law No. 103-62, (1993). The PAM model uses a claims-based sample and review methodology and has been designed to estimate a State-specific payment error rate that is within +/-3 percent of the true population error rate with 95 percent confidence. Moreover, through weighted aggregation, the State-specific estimates can be used to make national level improper payment estimates for the Medicaid and CHIP programs.
PAPD – Planning Advanced Planning Document
PBM – Pharmacy Benefits Management (PBM) is the procurement of prescription drugs at a negotiated rate for dispensation within a state to covered individuals, the administration or management of prescription drug benefits provided by a covered entity for the benefit of covered individuals, or any services provided with regard to the administration of pharmacy benefits.
PCCM – Primary Care Case Management (PCCM) is a Medicaid managed care program that provides case management through a client’s primary care provider (PCP).
PCP – A Primary Care Physician or Primary Care Provider (PCP) is a physician who provides primary care. The primary care physician acts as a gatekeeper to the medical system.
PDCS – Prescription Drug Card System
PDN – Private Duty Nurse/Nursing (PND) is a nurse who is not a member of a hospital staff, but is hired by the client or his/her family on a fee-for-service basis to care for the client. A nurse who specializes in the care of patients with diseases of a particular class.
PEER – The Joint Committee on Performance Evaluation and Expenditure Review (PEER) is a standing committee of the Mississippi Legislature. Created in 1973, PEER provides the Legislature with timely and accurate information on Mississippi state government in order to enable that body to perform its function of legislative oversight. PEER analyzes state agency programs and operations and helps the Legislature make state government more effective, efficient and accountable.
PHI – Protected Health Information
PHR – Personal Health Record
PHRM/ISS – Perinatal High Risk Management/Infant Services System (PHRM/ISS) is a multidisciplinary case management program established to help improve access to health care and to provide enhanced services to certain Medicaid-eligible pregnant/postpartum women and infants. The enhanced services for this target population include case management, psychosocial and nutritional counseling/assessments, home visits and health education.
PI – Program Integrity (PI) is a DOM bureau which identities and stops fraud and abuse in the Medicaid program by beneficiaries and providers.
PMPM – Per Member Per Month (PMPM) is the relative measure (the ratio) by which most expense and revenue, and many utilization comparisons are made.
POC – A Plan of Care (POC) is a written plan that directs what type of services and treatment are received.
PPACA (or ACA) – Patient Protection and Affordable Care Act of 2010
PPO – Preferred Provider Organization (PPO) is a network of medical providers.
PPS – Prospective Payment System
PQRI – The Physician Quality Reporting Initiative (PQRI) is a voluntary program that provides a financial incentive to physicians and other eligible professionals who successfully report quality data related to services provided under the Medicare Physician Fee Schedule (MPFS).
PRTF – A Psychiatric Residential Treatment Facility (PRTF) is a facility which provides psychiatric treatment for children under age 21 with mental/emotional/behavioral problems who do not require emergency or acute psychiatric care but who’s symptoms are severe enough to require supervision/intervention on a 24 hour basis.
PT – Physical Therapy (PT) is therapy that uses physical agents: exercise and massage and other modalities.
PTOS – Procedure Type of Service
QA – Quality Assurance (QA) is an ongoing process that ensures the delivery of agreed standards.
QI – Qualified Individuals
QIO – A Quality Improvement Organization (QIO) ensures quality assurance methods that emphasize the organization and systems: focuses on “process” rather than the individual; recognizes both internal and external “customers”; promotes the need for objective data to analyze and improve processes.
QMB – Qualified Medicare Beneficiaries (QMB) is a category of eligibility which pays Medicare premiums, deductibles and coinsurance for eligible individuals. To be eligible, a person must be eligible for Medicare, Part A (Hospital Insurance) and have a total monthly income that does not exceed the allowed maximum.
QWDI – Qualified Working Disabled Individual
RA – Remittance Advise (RA) formats for explaining the payments of health care claims.
RAC – Recovery Audit Contractor
RFI – A Request for information (RFI) is a formal request distributed to potential bidders and/or professional experts for information regarding a specific system, program, process or service.
RFP – A Request for Proposal (RFP) is a solicitation inviting proposals from vendors who believe they can provide products to satisfy an agency’s needs.
RHC – A Rural Health Clinic (RHC) is an outpatient facility that is primarily engaged in furnishing physicians’ and other medical and health services that also meets other requirements designated to ensure the health and safety of individuals served by the clinic. The clinic must be located in a medically under-served area that is not urbanized as defined by the U.S. Bureau of Census.
RN – A Registered Nurse is a graduate nurse who has passed examinations for registration.
RO – The Mississippi Division of Medicaid has 30 Regional Offices (ROs) which perform Medicaid eligibility determinations for applicants within the counties served by that RO.
RR – A Responsible Relative (RR) is a relative of a Medicaid beneficiary who assumes responsibility for conducting business on behalf of the beneficiary.
RR – Retro-Recovery (RR) is recovery of Medicaid funds from some third party after Medicaid has paid for medical services received by a Medicaid beneficiary.
RTF – A Resident Trust Fund (RTF) may belong to residents of Long Term Care facilities who may elect to allow a facility to manage a portion of their personal funds. These funds are audited by DOM on a regular basis to ensure facilities properly account for their funds in accordance with federal regulations.
SAMHSA – Substance Abuse and Mental Health Services Administration
SBAC – School Based Administrative Claims (SBAC) reimburses Mississippi public school districts enrolled in the program, for some health care outreach services that are not reimbursable under the School Health-Related Services Program.
SFTP – Secure File Transfer Protocol
SHRS – The School Health Related Services (SHRS ) Program was designed to identify children who have a learning problem because of a medical problem which requires special services. Once the child is identified an IEP (Individual Education Plan) listing services they need is then completed by the school. The schools have employed people with special training to assist children with special needs.
SIR – System Information Request (SIR) is a request submitted to the Medicaid for electronic solutions and data analysis.
SLMB – A Specified Low Income Medicare Beneficiary (SLMB) is a Medicaid category of eligibility which pays Medicare, Part B premium for qualified individuals. To be eligible, individuals must be age 65 or over or disabled, have income and resources below the maximum limits.
SLR – State Level Repository
SME – Subject Matter Expert
SMHP – State Medicaid Health Information Technology Plan
SNAP – Supplemental Nutrition Assistance Program
SNF – A Skilled Nursing Facility (SNF) is a nursing home which provides skilled nursing and/or skilled rehabilitation services to patients who need skilled medical care that cannot be provided in a custodial level nursing home or in the patient’s home.
SOP – Standard Operating Procedures (SOP) are a set of fixed instructions or steps for carrying out usually routine operations.
SOS – The Secretary of State is the appointed or elected official in a state government whose chief function is to distribute statutes, administer elections and keep archives. The Secretary of State for Mississippi is Delbert Hosemann.
SPA – A State Plan Amendment (SPA) is an alteration in the provisions under the State Plan.
SPB – State Personnel Board (SPB) is the state agency which recruits personnel for all Mississippi state agencies.
SPR – Summary Profile Report (SPR) is a statistical report of a medicaid provider’s or a medicaid beneficiary’s actions for a specific period of time which compares their behavior to the norm established for that period of time.
SSA – Social Security Administration (SSA) is the federal agency which administers payment of Social Security benefits and Supplemental Security Income (SSI).
SSI – Supplemental Security Income (SSI) is income provided by the U.S. government to needy aged, blind and disabled persons and administered by the Social Security Administration.
TANF – Temporary Assistance to Needy Families (TANF) is an assistance program for families.
TBI/SCI – Traumatic Brain Injury/Spinal Cord Injury is an acquired injury to the brain or spinal column caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects educational performance. The term applies to open and closed head injuries resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; and speech. The term does not apply to brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma.
TCN – A Transaction Control Number (TCN) is a unique identifier for a claim line assigned by the MMIS.
TCP/IP – Transmission Control Protocol and Internet Protocol (TCP/IP) is commonly known together as the Internet Protocol Suite.
TIN – Taxpayer Identification Number
TMA – Transitional Medical Assistance
TOS – Type of Service (TOS) is a code required on the Medicaid claim form.
TPL – Third Party Liability (TPL) insurance coverage a medicaid beneficiary has which the provider must file before submitting the claim to Medicaid as the payer of last resort.
UAT – User Acceptance Testing
UM/QIO – Utilization Management and Quality Improvement Organization
UR – Utilization Review (UR) is the process by which a plan determines whether a specific medical or surgical service is appropriate and/or medically necessary.
VA – Veteran’s Affairs
VFC – Vaccines for Children is a federally funded and state-operated program that began October 1994. The program provides vaccines free of charge to VFC eligible children through public and private providers. Providers are reimbursed by Medicaid for shot administration only.
WIC – The Women, Infants, Children (WIC) nutrition program provides free food and nutrition information to help keep pregnant women, infants and children under the age of five, healthy and strong. This program is run by the Mississippi Department of Health.
YTD – Year To Date, for the period starting Jan. 1 of the current year and ending today.