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Medicare Unit Vocab
| Term | Definition |
|---|---|
| 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
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