Medicare and Medical general terms



We update the list regularly so check back whenever you need to know anything in the realm of Medicare and Healthcare.


Annual Enrollment Period - The period from October 15 to December 7 when you can enroll in a Medicare Advantage plan or a stand-alone Prescription Drug Plan, or switch Medicare plans.


Appeal - A process to request your Medicare health plan to reconsider or perhaps change the decision of denying your request for coverage for the medical care coverage that you want.


Benefit period - The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you're admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven't gotten any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.


Catastrophic coverage - The part of the prescription drug benefit that kicks in after you have paid a certain amount in a calendar year.


Claim - A request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered.


Coinsurance - An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage.


Copayment - An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage.


Coverage gap - A period of time in which you pay higher cost-sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year.


Creditable coverage (Medigap) - Previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy.


Critical access hospital (CAH) - A small facility that provides outpatient services, as well as inpatient services on a limited basis, to people in rural areas.


Centers for Medicare & Medicaid Services (CMS) - The branch of the Department of Health and Human Services that administers Medicare.


Deductible - The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.


Durable medical equipment (DME) - Certain medical equipment, like a walker, wheelchair, or hospital bed, that's ordered by your doctor for use in the home.


ESRD - the end-stage renal disease is Permanent kidney failure that requires a transplant or dialysis.


Group health plan - In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.


Health care provider - A person or organization that's licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.


Home health agency - An organization that provides home health care.


Home health care - Health care services and supplies a doctor decides you may get in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.


Hospice - A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient's family or caregiver.


HIPAA – The Health Insurance Portability and Accountability Act - This Federal law has several components that provide for

  1. Portability of health care coverage

  2. Standards to be used when transmitting health information electronically

  3. Medical and administrative code sets to be used within those standards

  4. Identifiers to be utilized by providers, health plans, employers and individuals

  5. Measures required to protect the security and privacy of personally identifiable health care information.


IEP - Initial Enrollment Period is The 7-month period when you first can enroll in Medicare (3 months before you turn 65, the month of your birthday, and the 3 months afterward).


Long-term care - Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living, like dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living, or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.


Long-term care hospital - Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.


Medicare - Federal government program for any individual 65 or older (available for people under 65 with certain disabilities and end-stage renal disease) to help with medical costs.


Medicaid - Federal and sta program designed to help pay the medical cost for low-income individuals.


Medi-Cal - The official name of the Medicaid program in California.


Medicare eligibility - this term is used to describe and when someone is trying to determine if an individual has Medicare or is eligible for Medicare. Most providers utilize service vendors like us


Medically Necessary - Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.


Medicare-certified provider - A health care provider (like a home health agency, hospital, nursing home, or dialysis facility) that's been approved by Medicare. Providers are approved or "certified" by Medicare if they've passed an inspection conducted by a state government agency. Medicare only covers care given by providers who are certified.


Medicare Health Maintenance Organization (HMO) Plan - A type of Medicare Advantage Plan (Part C) available in some areas of the country. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan's list except in an emergency. Most HMOs also require you to get a referral from your primary care physician.


Medicare health plan - Generally, a plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs. Programs of All-inclusive Care for the Elderly (PACE) organizations are special types of Medicare health plans. PACE plans can be offered by public or private companies and provide Part D and other benefits in addition to Part A and Part B benefits.


Medicare Medical Savings Account (MSA) Plan - MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins.


Medicare Part A (Hospital Insurance) - Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.


Medicare Part B (Medical Insurance) - Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.


Medicare Preferred Provider Organization (PPO) Plan - A type of Medicare Advantage Plan (Part C) available in some areas of the country in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You can use doctors, hospitals, and providers outside of the network for an additional cost.


Medicare prescription drug coverage (Part D) - Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.


Medicare Private Fee-For-Service (PFFS) Plan - A type of Medicare Advantage Plan (Part C) in which you can generally go to any doctor or hospital you could go to if you had Original Medicare if the doctor or hospital agrees to treat you. The plan determines how much it will pay doctors and hospitals, and how much you must pay when you get care. A Private Fee-For-Service Plan is very different than Original Medicare, and you must follow the plan rules carefully when you go for health care services. When you're in a Private Fee-For-Service Plan, you may pay more or less for Medicare-covered benefits than in Original Medicare.


Medicare Savings Program - A Medicaid program that helps people with limited income and resources pay some or all of their Medicare premiums, deductibles, and coinsurance.


Medicare SELECT - A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.


Medicare Special Needs Plan (SNP) - A special type of Medicare Advantage Plan (Part C) that provides more focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic medical conditions.


Medicare Summary Notice (MSN) - A notice you get after the doctor, other health care provider, or supplier files a claim for Part A or Part B services in Original Medicare. It explains what the doctor, other health care provider, or supplier billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.


Medigap Open Enrollment Period - A one-time-only, 6-month period when federal law allows you to buy any Medigap policy you want that's sold in your state. It starts in the first month that you're covered under Part B and you're age 65 or older. During this period, you can't be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.


Original Medicare - Collective term for Medicare Parts A and B.


Payer – In health care, an entity that assumes the risk of paying for medical treatments. This can be a health plan, a self-insured employer, or an HMO.


Penalty - An amount added to your monthly premium for Part B or a Medicare drug plan (Part D) if you don't join when you're first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.


Point-of-service option - In a Health Maintenance Organization (HMO), this option lets you use doctors and hospitals outside the plan for an additional cost.


Premium - The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.


Preventive services - Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms).


Primary care doctor - The doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.


Programs of All-inclusive Care for the Elderly (PACE) - A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically necessary care and services based on your needs as determined by an interdisciplinary team. PACE serves frail older adults who need nursing home services but are capable of living in the community. PACE combines medical, social, and long-term care services and prescription drug coverage.


Referral - A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for the services.


RN - Registered nurse


Respite care - Temporary care provided in a nursing home, hospice inpatient facility, or hospital so that a family member or friend who is the patient's caregiver can rest or take some time off.


Secondary payer - The insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.


Skilled nursing care - are treatments that are given by a registered nurse (RN)


SNP - Special needs plan which is covered under the medicare advantage plan for people who are institutionalized, or entitled to both Medicare and state Medicaid benefits, or have certain chronic conditions.


SEP - Special Enrollment Period which is A time other than the annual election period or initial enrollment period when you may join, change, or drop a Medicare plan.


killed nursing facility (SNF) - A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.


Skilled nursing facility (SNF) care - Skilled nursing care and rehabilitation services provided on a daily basis, in a skilled nursing facility (SNF). Examples of SNF care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.


State Health Insurance Assistance Program (SHIP) - A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.


State Medical Assistance (Medicaid) office - A state or local agency that can give information about, and help with applications for, Medicaid programs that help pay medical bills for people with limited income and resources.


Supplemental Security Income (SSI) - A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 or older. SSI benefits aren't the same as Social Security retirement or disability benefits.


Supplier - Generally, any company, person, or agency that gives you a medical item or service, except when you're an inpatient in a hospital or skilled nursing facility.


Taxonomy Code – An administrative code set that classifies health care providers by type, classification, and specialization.


Telemedicine - Medical or other health services given to a patient using a communications system (like a computer, phone, or television) by a practitioner in a location different than the patients.


UPIN – Unique Physician Identification Number.


NPI - NATIONAL PROVIDER IDENTIFIER - The name of the standard unique health identifier for health care providers that was adopted by the Secretary in January 2004.


NNPI ENUMERATOR - An organization under contract with the Centers for Medicare & Medicaid Services whose responsibility includes, but is not limited to, the processing of applications for, and deactivations of, National Provider Identifiers (NPIs), and the processing of changes of information to health care providers' records contained in the National Plan and Provider Enumeration System (NPPES).


NPI REGISTRY - A publicly available, Internet-based real-time query database that displays publicly available health care provider data from the NPPES in response to a user's query.


(NPPES) - National Plan and Provider Enumeration System is the system that uniquely identifies a health care provider (as defined at 45 CFR 160.103) and assigns it an NPI.


Individual NPI (Type I) - This is your Type I NPI and each provider is required to have one in order to submit claims. This individual NPI is linked to the group that claims are submitted under.


Group NPI (Type II) - Referred to as an organizational NPI or technically as a Type II NPI. Your type I NPI is for the individual while your Type II is for your TAX ID or for locations under your tax id.


CAQH - Council of Quality Healthcare. The online repository used by insurance companies during the credentialing and re-credentialing process. Each provider is issued a CAQH ID number along with a username and password. It’s important to keep this information securely stored as you need to attest your information every 90 days.


Fee Schedule (Allowed Amount) - Your fee schedule is included in your contract with the insurance company(except for Medicare & Medicaid). These fee schedules state what the insurance company is willing to pay for services performed at your practice (allowed amount). If the allowed amount is $100 for a 99203, the insurance company is saying that this is what you should be paid. It doesn’t mean that the $100 will come from the insurer as most patients will have a coinsurance amount equal to 10-30%. This would mean that the insurance company would be $70-$90 and the patient would be responsible for the remaining balance. It’s important to load your fee schedules into your billing system so you can catch when payers are underpaying based on their contract. Medicare publishes a new fee schedule each year which includes all of the updated payment amounts for all CPT codes.


EDI - Electronic data interchange. Think of it as the highway between your billing system and the insurance company. It’s the communication channel by which your billing system communicates claim data to the various payers.


Clearinghouse - If EDI is the highway, your clearinghouse is the vehicle used to drive down the road. Your clearinghouse is connected to the billing system and is actually responsible for sending the claims to the insurance companies. Most clearinghouses will also receive the electronic remits (electronic EOBs) and send these to your billing system so the payments can be posted to the patient’s account.


EDI Enrollment - EDI enrollment occurs when you are setting up a new billing system/EHR or clearinghouse. Each clearinghouse has a unique submitter and receiver ID (for submitting claims and receiving remits) which must be linked to your tax id. You have to complete the EDI enrollment process in order to submit claims through your clearinghouse. A single entity can have multiple submitter IDs but can only have one receiving ID per PTAN for Medicare. Your billing or credentialing company should help walk you through this process.


ERA – Electronic remittance advice is a digital EOB(explanation of benefits) that shows what the insurance company paid (or didn’t pay) and all the claim details. Many billing systems can automatically post these ERAs to the patient’s account.


EFT - Electronic funds transfer is the preferred method of payment for many insurance companies and the required form of payment for Medicare. Medicare requires you to complete form CMS-588 when enrolling in Medicare which details how you would like to be paid.


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