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Medicare Unit Vocab

TermDefinition
Medicare federal health insurance [program created in 1965 as Title 18 of the Social Security Act (SSA). Managed by CMS (Centers for Medicare and Medicaid Services)
benefit period period of time that begins when an individual is admitted to a hospital or skilled nursing facility and ends 60 days after the discharge date; used to determine deductibles and co-payments for Medicare Part A
Medicare Advantage Manged care alternative to original Medicare FFS plan. Offering HMO/PPO style plans including Parts C and D.
Medicare Administrative Contractor Independent companies hired to process Medicare claims. Issue payments and claim decisions to providers and patients. Formerly known as fiscal intermediaries or insurance carriers
limiting fee maximum fee a provider may charge. For Medicare up to 15% above the Medicare Non-Par approved rate
Medigap supplemental plans designed by the federal government but sold by private commercial insurance companies to cover the costs of Medicare deductibles, co-payments, and co-insurance, which are considered "gaps" in medicare coverage.
Medicare Fee Schedule List of Medicare approved payment rates
Medicare/ Medicaid Crossover Program claims submitted to Medicare for Medicare/Medicaid beneficiaries, Medicare will pay the claim, apply a deductible/coinsurance or co-pay amount and then automatically forward the claim to Medicaid. Providers will not need to bill Medicaid separately
Advance Beneficiary Notice notice issued to patient prior to rendering of services when it is believed that Medicare will not cover the service that is planned.
health insurance claim number Medicare beneficiary ID number. The social security number of the wage earner followed by a one or two character alpha suffix
Suffix category A retired worker over 65 or disabled worker
Suffix category B spouse or former spouse
Suffix category C child (includes disable child or student)
Suffix category D deceased spouse
Suffix category E widowed mother
Suffix category F parent category for aged parents as dependents
Suffix category H disability claimant
Suffix category W disabled widow/widower
Created by: tina.reynolds