Definitions and Acronyms

270/271 Transactions

The ASC X12N eligibility inquiry (270) and response (271) transactions.

276/277 Transactions

The ASC X12 claim status request (276) and response (277) transactions.

278 Transactions

The ASC X12N request for services review and response used for prior authorization.

835 Transactions

The ASC X12N payment and remittance advice (explanation of benefits) transaction.

837 Transactions 

The ASC X12N professional, institutional, and dental claim transactions.

340B

Section 340B of the Public Health Service Act limits the cost of covered outpatient drugs to certain federal grantees, federally qualified health center look-alikes and qualified hospitals. Participation in the program results in significant savings estimated to be 20% to 50% on the cost of pharmaceuticals for qualified providers.

Accredited Standards Committee X12, Insurance Subcommittee (ASC X12N)

The ANSI-accredited standards development organization, and one of six Designated Standards Maintenance Organizations (DSMO), that was created and tasked with maintaining the administrative and financial transactions standards adopted under HIPAA for all health plans, clearinghouses, and providers who use electronic transactions.

Adjudication Cycle

The system processing of claims at the point where a decision has been made to pay, deny, or suspend.

Adjustment 

A transaction that changes any payment or other claim information on a previously paid claim.

Administrative Review 

Administrative reviews are the Department’s effort to resolve a grievance about a Department decision in order to avoid a hearing. The review includes an informal conference with the Department to review facts, legal authority, and circumstances involved in the adverse action by the Department.

Administrative Rules of Montana (ARM) 

The rules published by the executive departments and agencies of the state government.

Advanced Life Support (ALS) Assessment

An assessment performed by an ALS crew as part of an emergency response that was necessary because the member's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the member requires an ALS level of service.

Advanced Life Support Intervention

A procedure that is, in accordance with state and local laws, beyond the scope of authority of an emergency medical technician-basic (EMT-Basic).

Advanced Life Support Personnel

An individual trained to the level of the emergency medical technician-intermediate (EMT-Intermediate) or paramedic.

Allowed Amount

The maximum amount reimbursed to a provider for a healthcare service as determined by Medicaid/MHSP/HMK or another payer. Other cost factors, (such as cost sharing, third party liability (TPL), or incurment) are often deducted from the allowed amount before final payment. Medicaid's allowed amount for each covered service is listed on the Department fee schedule.

Ambulatory Payment Classification (APC)

APCs are the method of paying for facility outpatient services.

Ancillary Provider

Any provider who is subordinate to the member's primary provider, or providing services in the facility or institution that has accepted the patient as a Medicaid member.

Appropriate Facility

An institution generally equipped to provide the required hospital or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician or physician specialist is available to provide the necessary care to treat the member’s condition.

Assignment of Benefits

A voluntary decision by the member to have insurance benefits paid directly to the provider rather than to the member. The act requires the signing of a form for the purpose. The provider is not obligated to accept an assignment of benefits. However, the provider may require assignment in order to protect the provider's revenue.

Audit

A formal or periodic verification of accounts.

Authorization

An official approval for action taken for, or on behalf of, a Medicaid member. This approval is only valid if the member is eligible on the date of service.

Authorized Prescriber

A physician, osteopath, dentist, optometrist, mid-level practitioner, or other person duly authorized by law or rule in the State of Montana to prescribe drugs or services.

Average Acquisition Cost (AAC)Average acquisition cost (AAC) is the calculated average drug ingredient cost per drug determined by direct pharmacy survey, wholesale survey, and other relevant cost information. The AAC rates are published online under the Pharmacy Provider webpage. 

Average Wholesale Price (AWP)

The average wholesale price of a drug product from wholesalers nationwide at a point in time. The Department uses the AWP as reported by Medispan.

Bad Debt

Inpatient and outpatient hospital services for which a provider expected payment but full payment was not received because the patient or third party payer is unable or unwilling to pay the bill. Bad debts may be for services provided to patients who have no health insurance or patients who are underinsured and are net of payments made toward these services. For the purpose of uncompensated care, bad debt is measured on the basis of revenue forgone, at full established rates, and bad debt does not include either provider discounts or Medicare bad debt.

Balance Billing

Balance billing is when the provider bills patients for the difference between the amount the provider charged and the maximum allowed by the payer. Balance billing is considered fraudulent (ARM 37.85.406). However, HMK/CHIP dentists are allowed to bill after the dental limit has been reached.

Basic Medicaid

Patients with Basic Medicaid have limited Medicaid services. Refer to your provider type manual.

Birthing Center

A facility that provides comprehensive obstetrical care for women in which births are planned to occur away from the mother's usual residence following normal, uncomplicated, low risk pregnancy and is either (a) licensed outpatient center for primary care with medical resources as defined at MCA 50-5-101; or (b) a private office of a physician or certified nurse midwife that is accredited by a national organization as an alternative to a home birth or a hospital birth.

Brand Name

The proprietary or trade name selected by the manufacturer and placed upon a drug, its container, label, or wrapping at the time of packaging.

Bundled

Items or services that are deemed integral to performing a procedure or visit are not paid separately in the APC system. They are packaged (also called bundled) into the payment for the procedure or visit. Medicare developed the relative weights for surgical, medical, and other types of visits so that the weights reflect the packaging rules used in the APC method. Items or services that are packaged receive a status code of N.

Capped Rental

Rentals classified by Montana Medicaid and Medicare as capped rental items are limited to a 13-month rental period. Total monthly rental reimbursement is not to exceed 120% of the item’s purchase price. All necessary supplies needed to operate the rented equipment item are included in the rental amount. No additional allowances are made.

Carrier

A private insurance company.

Cash Option

Cash option allows the member to pay a monthly premium to Medicaid and have Medicaid coverage for the entire month rather than a partial month.

Centers for Medicare and Medicaid Services (CMS)

Administers the Medicare program and oversees the state Medicaid programs.

Change in Scope of Service

A change that affects the type, intensity, duration, and/or amount of services provided by a health center.

Children's Health Insurance Plan (CHIP)

This Montana plan is now known as Healthy Montana Kids (HMK).

Children's Special Health Services (CSHS)

CSHS assists children with special healthcare needs who are not eligible for Medicaid by paying medical costs, finding resources, and conducting clinics.

Claims Attachment

Supplemental information about the services provided to a member that supports medical or other evaluation for payment, post-payment review, or quality control requirements that are directly related to one or more specific services billed on the claim.

Claims Clearinghouse

When a provider contracts with a clearinghouse, the clearinghouse supplies the provider with software that electronically transmits claims to the clearinghouse. The clearinghouse then transmits the claims to the appropriate payers.

Clean Claim

A claim that can be processed without additional information from or action by the provider of the service.

Code of Federal Regulations (CFR)

Rules published by executive departments and agencies of the federal government.

Coinsurance

The member's financial responsibility for a medical bill as assigned by Medicare (usually a percentage). Medicare coinsurance is usually 20% of the Medicare allowed amount.

Commercial Transportation

Travel services provided by air or ground commercial carrier, taxicab, or bus for a Medicaid member to receive medical care.

Compounding

The act of combining two or more active ingredients or adjusting therapeutic strengths in the preparation of a prescription.

Conversion Factor

A state specific dollar amount that converts relative values into an actual fee. This calculation allows each payer to adopt the RBRVS to its own economy.

Copayment

The member’s financial responsibility for a medical bill as assigned by Medicaid (usually a flat fee).

Cosmetic

Serving to modify or improve the appearance of a physical feature, defect, or irregularity.

Cost Sharing

The member's financial responsibility for a medical bill assessed by flat fee or percentage of charges.

Covered Outpatient Drug

A drug approved for safety and effectiveness as a prescription drug under the federal Food, Drug, and Cosmetic Act, and manufactured or distributed by manufacturers/labelers who have signed a drug rebate agreement with the Federal Department of Health and Human Services (DHHS).

Credit Balance Claims

Adjusted claims that reduce original payments, causing the provider to owe money to the Department. These claims are considered in process and continue to appear on the remittance advice until the credit has been satisfied.

Critical Access Hospital

A limited-service rural hospital licensed by DPHHS.

Crossovers

Claims for members who have both Medicare and Medicaid. These claims may come electronically from Medicare or directly from the provider.

Current Procedural Terminology (CPT)

Physicians' Current Procedural Terminology contains procedure codes which are used by medical practitioners in billing for services rendered. The book is published by the American Medical Association.

Dental Service

The medically necessary treatment of the teeth and associated structures of the oral cavity. Dental service includes the provision of orthodontia and prosthesis for HMK Plus members. Dental services for HMK members do not include orthodontia and prosthesis.

Denturist Services

Full or partial denture services that are provided by a licensed denturist. Services provided must be within the scope of their profession as defined by law.

DESI (Drug Efficacy Study Index) or ("less than effective drugs")

An index that measures one drug against a clinical response criteria. If the index is low, the drug is classified as less than effective.

Dialysis Clinic

Clinics that provide dialysis services to members suffering from end-stage renal disease (ESRD).

Direct Nursing Care

The care given directly to a member that requires the skills and expertise of an RN or LPN.

Discharging Hospital

A hospital, other than a transferring hospital, which formally discharges an inpatient. The release of a patient to another hospital or a leave of absence from the hospital is not considered a discharge.

Dispense

The interpretation of a prescription or order for a legend drug and, pursuant to that prescription or order, the proper selection, measuring, compounding, labeling, or packaging necessary to prepare that prescription or order for delivery.

Dispensing Fee

A fee set by the Department to reimburse pharmacies for their administrative costs incurred in filling prescriptions for members.

Disposition

The end result of processing a claim is the assignment of a status or disposition.

Distinct Part Rehabilitation Unit

A unit of an acute care general hospital that meets the requirements in 42 CFR 412.25 and 412.29.

DPHHS, State Agency

The Montana Department of Public Health and Human Services (DPHHS or the Department) is the designated State Agency that administers the Montana Healthcare Programs. The Department's legal authority is contained in Title 53, Chapter 6 MCA. At the federal level, the legal basis for the program is contained in Title XIX of the Social Security Act and Title 42 of the Code of Federal Regulations (CFR). The program is administered in accordance with the Administrative Rules of Montana (ARM), Title 37, Chapter 86.

Drug Utilization Review (DUR) Program

A quality assurance program for covered outpatient drugs which assures that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical outcomes.

Dual Eligibles

Members who are covered by Medicare and Medicaid are often referred to as dual eligibles.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program

This program provides Medicaid-covered children with comprehensive health screenings, diagnostic services, and treatment of health problems.

Electronic Data Interchange (EDI)

The communication of information in a stream of data from one party’s computer system to another party’s computer system.

Electronic Funds Transfer (EFT)

Payment of medical claims that are deposited directly to the provider's bank account. Sometimes referred to as direct deposit.

Electronic Remittance Advice (ERA)

The results of claims processing (including paid, denied, and pending claims) are listed on the remittance advice.

Emergency Medical Condition

A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could result in:

• Placing the health of the individual in serious jeopardy;

• Serious impairment to body functions; or

• Serious dysfunction of any bodily organ or part; or

With respect to a pregnant woman who is having contractions:

• There is inadequate time to effect a safe transfer to another hospital before delivery; or

• Transfer may post a threat to the health or safety of the woman or the unborn child.

Emergency Response

Responding immediately at the BLS or ALS1 level of service to a 911 call or the equivalent in areas without a 911 call system.

Emergency Services

A service is reimbursed as an emergency if one of the following criteria is met:

• The service is billed with CPT Code 99284 or 99285

• The member has a qualifying emergency diagnosis code. A list of emergency diagnosis codes is available on the Provider Information website.

• The services did not meet one of the previous two requirements, but the hospital believes an emergency existed. In this case, the claim and documentation supporting the emergent nature of the service must be mailed to the emergency department review contractor (see Key Contacts on your provider type page or in your provider manual).

EMT – Basic

An individual who is qualified in accordance with state and local laws as an EMT-Basic.

EMT – Intermediate

An individual who is qualified in accordance with state and local laws as an EMT-Intermediate.

EMT – Paramedic

An individual who is qualified in accordance with state and local laws as an EMT-Paramedic.

Essential for Employment Services for Basic Medicaid Members

Medicaid may reimburse for dental, DME, optometric, audiology, and hearing aid services for recipients who are employed or have been offered employment. Refer to the Covered Services and Limitations chapter of your provider manual for more information related to this service.

Estimated Acquisition Cost (EAC)

The Department's best estimate of the price providers generally and currently pay for a drug marketed or sold by a particular manufacturer or labeler in the package size most frequently purchased by providers.

Experimental

A noncovered item or service that researchers are studying to investigate how it affects health.

Explanation of Benefits (EOB) Codes

A 3-digit code on a Medicaid remittance advice that explains why a claim was denied or suspended. The explanation of the EOB codes is found at the end of the remittance advice.

Explanation of Medicare Benefits (EOMB)

A notice sent to providers informing them of the services which have been paid by Medicare.

Fair Hearing

Providers may request a fair hearing when the provider believes the Department’s administrative review determination fails to comply with applicable laws, regulations, rules or policies. Fair hearings include a hearings officer, attorneys, and witnesses for both parties.

Fiscal Agent

Conduent State Healthcare, LLC, is the fiscal agent for the State of Montana and processes claims at the Department's direction and in accordance with ARM 37.86 et seq.

Free Care Rule

If a service is free to non-Medicaid members, then it must also be free to Medicaid members. Medicaid cannot be billed for services that are provided free to non-Medicaid members.

Frequently Maintained Rental

Rentals that need frequent and substantial servicing are not subject to a cap and the provider may continue to rent the item as long as it is medically necessary. All supplies needed to operate the equipment are included in the rental fee.

Full Medicaid

Patients with Full Medicaid have a full scope of Medicaid benefits. See the General Information for Providers manual, Medicaid Covered Services.

Generic Equivalents

Drug products are considered pharmaceutical equivalents if they contain the same active ingredient(s), are of the same dosage form and are identical in strength or concentration, and route of administration. They may differ in characteristics such as shape, scoring configuration, packaging, excipients (including colors, flavors, preservatives), expiration time, and within certain limits, labeling. (FDA Approved Drug Products with Equivalence Evaluations, 12th Edition, 1992.)

Generic Name

The official title of a drug or drug ingredients published in the latest edition of a nationally recognized pharmacopoeia or formulary.

Gross Adjustment

A lump sum debit or credit that is not claim specific made to a provider.

HCPCS

Acronym for the Healthcare Common Procedure Coding System, and is pronounced hick-picks. There are two types of HCPCS codes:

• Level 1 includes the CPT codes.

• Level 2 includes the alphanumeric codes A–V which CMS maintains for a wide range of services from ambulance trips to hearing aids which are not addressed by CPT coding.

Health Improvement Program (HIP)

A service provided under the Passport to Health program for members who have one or more chronic health conditions. Care management focuses on helping members improve their health outcomes through education, help with social services, and coordination with the member's medical providers.

Health Insurance Portability and Accountability Act (HIPAA)

A federal plan designed to improve efficiency of the healthcare system by establishing standards for transmission, storage, and handling of data.

Healthy Montana Kids (HMK)

HMK offers low-cost or free healthcare coverage for low-income children younger than 19. Children must be uninsured U.S. citizens or qualified aliens, Montana residents who are not eligible for Medicaid. DPHHS administers the program with Blue Cross and Blue Shield of Montana (BCBSMT).  For information about medical benefits, contact BCBSMT at 1.406.447.8647 (Helena) or 1.800.447.7828 (toll-free). HMK dental and eyeglasses benefits are provided by DPHHS through the same contractor (Conduent State Healthcare, LLC) that handles Medicaid provider relations and claims processing.

Healthy Montana Kids Plus (HMK Plus)

Medicaid eligibility group for children under age 19.

Homebound

Normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort.

Home Dialysis

Dialysis performed by an appropriately trained patient at home.

Hospital Resident

A member who is unable to be cared for in a setting other than the acute care hospital.

Immediate Response

The ambulance provider begins as quickly as possible to take the steps necessary to respond to the call.

Incurment

That portion of a medically needy individual's or couple's income that exceeds the Medically Needy Income Level (MA 002); the amount of medical expenses for which the individual is responsible before Medicaid will begin paying any medical bills.

Independent Entity

A rural health clinic or federally qualified health center that is not a provider-based entity.

Indian Health Service (IHS)

IHS provides health services to American Indians and Alaska Natives.

Individual Adjustment

A request for a correction to a specific paid claim.

Inpatient

A member who has been admitted to a hospital with the expectation that he/she will remain more than 24 hours.

Internal Control Number (ICN)

The unique number assigned to each claim transaction that is used for tracking.

International Classification of Disease (ICD)

The International Classification of Diseases contains the diagnosis codes used in coding claims and the procedure codes used in billing for services performed in a hospital setting.

Investigational

A non-covered item or service that researchers are studying to investigate how it affects health.

Legend or Prescription Drugs

Any drugs required by any applicable federal or state law or regulation to be dispensed by prescription only or which are restricted to use by practitioners only.

Less Than Effective Drugs

See DESI.

Lock-in Pharmacy

Medicaid will reimburse for medications at only the lock-in pharmacy. If medications must be dispensed by a different pharmacy, the pharmacy must call the enrollment broker to authorize payment.

Loop Trip

A "loop trip" is performed when a member requires scheduled non-emergency service and is transported to the service and returned to the point of origin on the same day.

Mass Adjustment

Adjustments made to multiple claims at the same time. They generally occur when the Department has a change of policy or fees that is retroactive, or when a system error that affected claims processing is identified.

Maximum Allowable

The maximum dollar amount a provider may be reimbursed for specific services, supplies, or equipment.

Maximum Allowable Cost (MAC) Program

The maximum amount paid for a specified dosage form and strength of a multiple source drug product.

Medicaid/HMK Plus

A program that provides healthcare coverage to specific populations, especially low-income families with children, pregnant women, disabled people and the elderly. Medicaid is administered by state governments under broad federal guidelines.

Medical Assistance

The federal aid Title XIX program under which medical care is provided to the categorically needy.

Medically Accepted Indication

Any use for a covered outpatient drug which is approved under the Federal Food, Drug and Cosmetic Act, which appears in peer-reviewed medical literature or which is accepted by one or more of the following compendia:

• The American Hospital Formulary Service Drug Information;

• The American Medical Association Drug Evaluations;

• The United States Pharmacopoeia Drug Information; or

• DRUGDEX.

Medically Necessary

A term describing a requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the member. These conditions must be classified as one of the following: endanger life, cause suffering or pain, result in an illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There must be no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the member requesting the service. For the purpose of this definition, "course of treatment" may include mere observation or, when appropriate, no treatment at all.

Medically Unlikely Edits (MUE)

Edit to pay only the maximum units allowed for a single provider for the same member on the same date of service.

Medicare

The federal health insurance program for certain aged or disabled members.

Member

An individual enrolled in a Department medical assistance program.

Mental Health Services Plan (MHSP)

This plan is for individuals who have a severe disabling mental illness (SDMI), are ineligible for Medicaid, and have a family income that does not exceed an amount established by the Department.

Mentally Incompetent

According to CFR 441.251, a mentally incompetent individual means an individual who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared incompetent for purposes which include the ability to consent to sterilization.

Minimal Services

According to CPT, when member's visit does not require the presence of the physician, but services are provided under the physician's supervision, they are considered minimal services. An example would be a patient returning for a monthly allergy shot.

Montana Access to Health (MATH) Web Portal

A secure website on which providers may view members' medical history, verify member eligibility, submit claims to Medicaid, check the status of a claim, verify the status of a warrant, and download remittance advice reports.

Montana Breast and Cervical Cancer Treatment Program

This program provides Full Medicaid coverage for women who have been screened through the Montana Breast and Cervical Health Program (MBCHP) and diagnosed with breast and/or cervical cancer or a pre-cancerous condition.

Montana Healthcare Programs

Multiple benefit programs within the DPHHS that includes Medicaid, Mental Health Services Plan (MHSP), and Health Montana Kids (HMK).

Multiple Source Drug

A drug marketed or sold by two or more manufacturers or labelers or a drug marketed or sold by the same manufacturer or labeler under two or more different proprietary names or both under a proprietary name.

Mutually Exclusive Code Pairs

These codes represent services or procedures that, based on either the CPT definition or standard medical practice, would not or could not reasonably be performed at the same session by the same provider on the same patient. Codes representing these services or procedures cannot be billed together.

NABP

National Association of Boards of Pharmacies.

National Council on Prescription Drug Programs (NCPDP)

The national standards organization for pharmacy claims submission.

National Drug Code (NDC)

An 11-digit number the manufacturer assigns to a pharmaceutical product and attaches to the product container at the time of packaging that identifies the product's manufacturer, dose form and strength, and package size.

National Provider Identifier (NPI)

NPI is a unique 10-digit identification number required by HIPAA for all healthcare providers in the United States. Providers must use their NPI to identify themselves in all HIPAA transactions.

Newsletter

An informational letter sent to providers (e.g., Montana Healthcare Programs Claim Jumper).

Non-Rebate Drugs

Drugs manufactured or distributed by manufacturers/labelers who have not signed a drug rebate agreement with the Federal Department of Health and Human Services (DHHS) or the state Department of Public Health and Human Services (DPHHS).

Obsolete Drug

A drug that has been identified as obsolete by the manufacturer and is no longer available.

Obsolete NDC

A national drug code replaced or discontinued by the manufacturer or labeler.

Outpatient

A person who has not been admitted by a hospital as an inpatient, who is expected by the hospital to receive services in the hospital for less than 24 hours, who is registered on the hospital records as an outpatient, and who receives outpatient hospital services, other than supplies or prescription drugs alone, from the hospital.

Outpatient Hospital Services

Outpatient hospital services are those preventive, diagnostic, therapeutic, rehabilitative, palliative items or services provided to an outpatient by or under the direction of a physician, dentist, or other practitioner.

Outpatient Maintenance Dialysis

Dialysis furnished on an outpatient basis at a renal dialysis center or facility. Outpatient dialysis includes staff-assisted dialysis, self-dialysis, and home dialysis.

Outpatient Prospective Payment System (OPPS)

Medicare's outpatient prospective payment system mandated by the 1999 Balanced Budget Refinement Act (BBRA) and the 2000 Medicare, Medicaid, SCHIP Benefits Improvement and Protection Act (BIPA).

Over-the-Counter (OTC) Drug

Drugs (non-legend) that do not require a prescription before they can be dispensed.

Packaged

Items or services that are deemed integral to performing a procedure or visit are not paid separately in the APC system. They are packaged (also called bundled) into the payment for the procedure or visit. Medicare developed the relative weights for surgical, medical, and other types of visits so that the weights reflect the packaging rules used in the APC method. Items or services that are packaged receive a status code of "N".

Passport Referral Number

This is a 7-digit number assigned to Passport providers. When a Passport provider refers a member to another provider for services, this number is given to the other provider and is required when processing the claim.

Passport to Health

The Medicaid primary care case management program where the member selects a primary care provider who manages the member’s healthcare needs.

Pay-and-Chase

Medicaid pays a claim and then recovers payment from the third party carrier that is financially responsible for all or part of the claim.

Pending Claim

These claims have been entered into the system, but have not reached final disposition. They require either additional review or are waiting for member eligibility information.

Pharmacist

A person duly licensed by the Montana State Board of Pharmacy to engage in the practice of pharmacy.

Pharmacy

Every site properly licensed by the Board of Pharmacy in which practice of pharmacy is conducted.

Point-of-Sale (POS)

A pharmacy claims processing system capable of adjudicating claims online.

Potential Third Party Liability

Any entity that may be liable to pay all or part of the medical cost of care for a Medicaid, MHSP, or HMK member.

Preferred Drug List (PDL)

A list developed by the DUR Board of outpatient drugs covered by the Prescription Drug Program, including products with limited coverage and requiring prior authorization.

Prescription

An order for drugs or devices issued by a practitioner duly authorized by law or rule in the State of Montana to prescribe drugs or devices in the course of his or her professional practice for a legitimate medical purpose.

Prior Authorization

The approval process required before certain services or supplies are paid by Medicaid. Prior authorization must be obtained before providing the service or supply.

Private-Pay

When a member chooses to pay for medical services out of his/her own pocket.

Prospective Drug Use Review (Pro-DUR)

A process in which a request for a drug product for a particular patient is screened for potential drug therapy problems before the drug is dispensed while the prescription claim is submitted to the Medicaid payer.

Protocols

Written plans developed by a public health clinic in collaboration with physician and nursing staff. Protocols specify nursing procedures to be followed in giving a specific exam, or providing care for particular conditions. Protocols must by updated and approved by a physician at least annually.

Provider/Provider of Service

An institution, agency, or person having a signed agreement with the Department to furnish medical care, goods and/or services to members, and eligible to receive payment from the Department.

Provider-Based Entity

A federally qualified health center or rural health clinic that is an integral or subordinate part of a hospital, skilled nursing facility, or home health agency that is participating in the Medicare program and that is operated with other departments of the provider under the common licensure, governance and professional supervision.

Provider Number

Number issued by the Department, for reimbursement.

Qualified Individual

For these members, Medicaid pays the Medicare premium only. They are not eligible for other Medicaid benefits, and they must pay their own Medicare insurance and deductibles.

Qualified Medicare Beneficiary (QMB)

QMB members are members for whom Medicaid pays their Medicare premiums and some or all of their Medicare coinsurance and deductibles.

Reason and Remark Code

A code printed on the Medicaid remittance advice that explains why a claim was denied or suspended. The explanation of  the Reason and Remark codes is at the end of the remittance advice.

Rebilling

When a provider submits a claim that was previously submitted for payment but was either returned or denied.

Reference Lab Billing

Reference lab billing occurs when a Medicaid provider draws a specimen and sends it to a reference lab for processing. The reference lab then sends the results back to the Medicaid provider. Medicaid does not cover lab services when they are billed by the referring provider.

Referral

When providers refer members to other Medicaid providers for medically necessary services that they cannot provide.

Relative Value Scale (RVS)

A numerical scale designed to permit comparisons of appropriate prices for various services. The RVS is made up of the relative value units (RVUs) for all the objects in the class for which it is developed.

Relative Value Unit (RVU)

The numerical value given to each service in a relative value scale.

Remittance Advice (RA)

The results of claims processing (including paid, denied, and pending claims) are listed on the RA.

Remittance Advice Notice

The first page of the remittance advice that contains important messages for providers.

Reporting Period

A period of 12 consecutive months specified by a federally qualified health center or rural health clinic as the period for which the entity must report its costs and utilization. The reporting period must correspond to the provider’s fiscal year. The first and last reporting periods may be less than 12 months.

Resource-Based Relative Value Scale (RBRVS)

A method of determining physicians' fees based on the time, training, skill, and other factors required to deliver various services.

Retroactive Eligibility

When a member is determined to be eligible for Medicaid effective prior to the current date.

Retrospective Drug Use Review (Retro-DUR)

The process in which drug utilization by patients is reviewed on a periodic basis to identify patterns of fraud, abuse, gross overuse, or inappropriate or unnecessary care.

Routine Podiatric Care

Routine podiatric care includes the cutting or removing of corns and calluses, the trimming of nails, the application of skin creams, and other hygienic, preventive maintenance care and debridement of nails.

Sanction

The penalty for noncompliance with laws, rules, and policies regarding Medicaid. A sanction may include withholding payment from a provider or terminating Medicaid enrollment.

School-Based Services

Medically necessary health-related services provided to Medicaid-eligible children up to and including age 20. These services are provided in a school setting by licensed medical professionals.

Self-Dialysis

Dialysis performed by an ESRD patient who has completed an appropriate course of training with little or no professional assistance.

Severe Disabling Mental Illness (SDMI)

Click here for a complete definition of SDMI.

Severe Emotional Disturbance (SED)

For a complete definition of SED please visit the Children’s Mental Health Bureau Medicaid Services Provider Manual.

Single Source Drug

A drug produced or distributed under an original new drug application approved by the FDA, including a drug product marketed by any cross-licensed producers or distributors operating under the new drug application.

Span Billing

Billing for a range of dates of service on one line of a claim (e.g. billing for 01/01/03–01/30/03 on one line). Medicaid does not allow span billing for transportation claims.

Specialized Non-Emergency Transportation

Transport in a van designed for wheelchair or stretcher bound members, which is operated by a provider with a class B public service commission license. This type of service does not require the same level of care as an ambulance, and members using this service must have a disability or physical limitation that prevents them from using other forms of transportation to obtain medical services. Medicaid does not cover specialized non-emergency transports when another mode of transportation is appropriate and less costly.

Specified Low-Income Medicare Beneficiaries (SLMB)

For these members, Medicaid pays the Medicare premium only. They are not eligible for other Medicaid benefits, and must pay their own Medicare coinsurance and deductibles.

Spending Down

Members with high medical expenses relative to their income can become eligible for Medicaid by "spending down" their income to specified levels. The member is responsible to pay for services received before eligibility begins, and Medicaid pays for remaining covered services.

Staff-Assisted Dialysis

Dialysis performed by the staff of the center or facility.

State Maximum Allowable Cost (SMAC) Program

The maximum amount paid for a specified dosage form and strength of a multiple source drug product.

Submitted Ingredient Cost

Submitted Ingredient is a pharmacy’s actual ingredient cost. For drugs purchased under the 340B Drug Pricing Program, submitted ingredient cost means the actual 340B purchase price. For drugs purchased under the Federal Supply Schedule (FSS), submitted ingredient cost means the actual FSS purchase price.

Submitter

The healthcare provider identified on the signature line of the Medicaid agreement.

Taxonomy

Taxonomy codes are used to identify and code an external provider table that would be able to standardized provider types and provider areas of specialization for all medical-related providers.

Team Care

A restricted services program that is part of Passport to Health. Restricted services programs are designed to assist members in making better healthcare decisions so that they can avoid overutilizing health services. Team Care members are joined by a team assembled to assist them in accessing healthcare. The team consists of the member, the PCP, a pharmacy, the Department, and the Nurse First Advice Line. The team may also include a community-based care manager from the Department's Health Improvement Program.

Terminated Drug Product

A product whose shelf life expiration date has been met, per manufacturer notification.

Therapeutic Equivalent

Drug products are considered to be therapeutic equivalents only if they are pharmaceutical equivalents and if they can be expected to have the same clinical effect and safety profile when administered to patients under the conditions specified in the labeling (FDA Approved Drug Products with Therapeutic Equivalence Evaluations, 23rd Edition, March 2003).

Third Party Liability (TPL)

Any entity that is, or may be, liable to pay all or part of the medical cost of care for a Medicaid, MHSP, or HMK member.

Timely Filing

Providers must submit clean claims (claims that can be processed without additional information or documentation from or action by the provider) to Medicaid within:

• 12 months from whichever is later:

  • The date of service.

  • The date retroactive eligibility or disability is determined.

• 6 months from the date on the Medicare explanation of benefits approving the service.

• 6 months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above.

Trading Partner

EDI Solutions, a subsidiary of Conduent State Healthcare, LLC, provides healthcare electronic data interchange (EDI) services for government plans and commercial healthcare insurers.

Transferring Hospital

A hospital that formally releases an inpatient to another inpatient hospital or inpatient unit of a hospital.

Trip Log

A form that providers can use for transport notification purposes. This form is available on the Provider Information website.

Trip Report

The medical record documented during the ambulance run.

Unit Dose Delivery

A drug delivery system in which each patient's medication is delivered in quantities sufficient only for the day's required dosage.

Urgent Transport

When a member's health problem is not life threatening, but is serious enough to obtain help.

Usual and Customary

The fee that the provider most frequently charges the general public for a service or item.

WINASAP 5010

WINASAP 5010 is a Windows-based electronic claims entry application for Montana Medicaid. This free software was developed as an alternative to submitting claims on paper. For more information contact Montana EDI at 1.800.987.6719.